Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Mild Traumatic Brain Injury: Approved by ACEP Board of Directors, February 1, 2023 Clinical Policy Endorsed by the Emergency Nurses Association (April 5, 2023)

This 2023 Clinical Policy from the American College of Emergency Physicians is an update of the 2008 “Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.” A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following questions: 1) In the adult emergency department patient presenting with minor head injury, are there clinical decision tools to identify patients who do not require a head computed tomography? 2) In the adult emergency department patient presenting with minor head injury, a normal baseline neurologic examination, and taking an anticoagulant or antiplatelet medication, is discharge safe after a single head computed tomography? and 3) In the adult emergency department patient diagnosed with mild traumatic brain injury or concussion, are there clinical decision tools or factors to identify patients requiring follow-up care for postconcussive syndrome or to identify patients with delayed sequelae after emergency department discharge? Evidence was graded and recommendations were made based on the strength of the available data. Widespread and consistent implementation of evidence-based clinical recommendations is warranted to improve patient care.

Biological activities of meroterpenoids isolated from different sources

Meroterpenoids are natural products synthesized by unicellular organisms such as bacteria and multicellular organisms such as fungi, plants, and animals, including those of marine origin. Structurally, these compounds exhibit a wide diversity depending upon the origin and the biosynthetic pathway they emerge from. This diversity in structural features imparts a wide spectrum of biological activity to meroterpenoids. Based on the biosynthetic pathway of origin, these compounds are either polyketide-terpenoids or non-polyketide terpenoids. The recent surge of interest in meroterpenoids has led to a systematic screening of these compounds for many biological actions. Different meroterpenoids have been recorded for a broad range of operations, such as anti-cholinesterase, COX-2 inhibitory, anti-leishmanial, anti-diabetic, anti-oxidative, anti-inflammatory, anti-neoplastic, anti-bacterial, antimalarial, anti-viral, anti-obesity, and insecticidal activity. Meroterpenoids also possess inhibitory activity against the expression of nitric oxide, TNF- α, and other inflammatory mediators. These compounds also show renal protective, cardioprotective, and neuroprotective activities. The present review includes literature from 1999 to date and discusses 590 biologically active meroterpenoids, of which 231 are from fungal sources, 212 are from various species of plants, and 147 are from marine sources such as algae and sponges.

Full-face motorcycle helmets to reduce injury and death: A systematic review, meta-analysis, and practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

While motorcycle helmets reduce mortality and morbidity, no guidelines specify which is safest. We sought to determine if full-face helmets reduce injury and death.

METHODS

We searched for studies without exclusion based on: age, language, date, or randomization. Case reports, professional riders, and studies without original data were excluded. Pooled results were reported as OR (95% CI). Risk of bias and certainty was assessed. (PROSPERO #CRD42021226929).

RESULTS

Of 4431 studies identified, 3074 were duplicates, leaving 1357 that were screened. Eighty-one full texts were assessed for eligibility, with 37 studies (n = 37,233) eventually included. Full-face helmets reduced traumatic brain injury (OR 0.40 [0.23-0.70]); injury severity for the head and neck (Abbreviated Injury Scale [AIS] mean difference -0.64 [-1.10 to -0.18]) and face (AIS mean difference -0.49 [-0.71 to -0.27]); and facial fracture (OR 0.26 [0.15-0.46]).

CONCLUSION

Full-face motorcycle helmets are conditionally recommended to reduce traumatic brain injury, facial fractures, and injury severity.

The Impact of a Medical Education Research Faculty Development Program on Career Development, Through the Lens of Social Cognitive Career Theory

OBJECTIVES

The Medical Education Research Certificate at the Council of Residency Directors in Emergency Medicine (MERC at CORD), a specialized adaptation of the Association of American Medical Colleges MERC program, provides faculty development in education research in emergency medicine. However, its long-term influence on career development remains unknown. Our study explored the impact of MERC at CORD on career development through the lens of social cognitive career (SCC) theory.

METHODS

This was a prospective qualitative study using a constructivist/interpretivist paradigm to assess long-term career development outcomes. A purposeful randomized stratified sampling strategy of MERC at CORD graduates (2011-2014) ensured diversity of representation (sex, region, number of research publications, and project group leadership). Subjects were invited by e-mail to participate in semistructured phone interviews. Thematic analysis by two independent reviewers followed an iterative process until saturation was reached.

RESULTS

Twelve graduates were interviewed. All engaged with MERC at CORD early in their careers with minimal previous education research experience. Currently, all hold medical education leadership positions. Graduates had a mean of 19.3 publications (range = 9-43). Themes explaining reasons for participating in MERC at CORD include: desire for education research skills, recommendation of mentors/colleagues, and accessibility. Themes citing the program's value to career development include networking/collaboration, mentorship, informational framework to build upon, and the application of theoretical knowledge through experiential learning. MERC at CORD impacted career development aligning with the core domains of SCC theory including self-efficacy, outcome expectations, and goals.

CONCLUSION

MERC at CORD enhanced the long-term career development of participants by providing a core knowledge framework in a mentored, experiential learning environment. Participants identified themes aligned with SCC theory as influential in their long-term career advancement in medical education including the development of education research skills, successful completion of education research, career acceleration, promotion, niche development, and formulation of professional goals.

ACR Appropriateness Criteria® Acute Trauma to the Foot

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

How Well Does the Standardized Video Interview Score Correlate with Traditional Interview Performance?

Introduction

In 2017, all medical students applying for residency in emergency medicine (EM) were required to participate in the Standardized Video Interview (SVI). The SVI is a video-recorded, uni-directional interview consisting of six questions designed to assess interpersonal and communication skills and professionalism. It is unclear whether this simulated interview is an accurate representation of an applicant’s competencies that are often evaluated during the in-person interview.

Objective

The goal of this study was to determine whether the SVI score correlates with a traditional in-person interview score.

Methods

Six geographically and demographically diverse EM residency programs accredited by the Accreditation Council for Graduate Medical Education participated in this prospective observational study. Common demographic data for each applicant were obtained through an Electronic Residency Application Service export function prior to the start of any scheduled traditional interviews (TI). On each TI day, one interviewer blinded to all applicant data, including SVI score, rated the applicant on a five-point scale. A convenience sample of applicants was enrolled based on random assignment to the blinded interviewer. We studied the correlation between SVI score and TI score.

Results

We included 321 unique applicants in the final analysis. Linear regression analysis of the SVI score against the TI score demonstrated a small positive linear correlation with an r coefficient of +0.13 (p=0.02). This correlation remained across all SVI score subgroups (p = 0.03).

Conclusion

Our study suggests that there is a small positive linear correlation between the SVI score and performance during the TI.

The Standardized Video Interview: How Does It Affect the Likelihood to Invite for a Residency Interview?

BACKGROUND

The Association of American Medical Colleges instituted a standardized video interview (SVI) for all applicants to emergency medicine (EM). It is unclear how the SVI affects a faculty reviewer's decision on likelihood to invite an applicant (LTI) for an interview.

OBJECTIVES

The objective was to determine whether the SVI affects the LTI.

METHODS

Nine Accreditation Council of Graduate Medication Education (ACGME)-accredited EM residency programs participated in this prospective, observational study. LTI was defined on a 5-point Likert scale as follows: 1 = definitely not invite, 2 = likely not invite, 3 = might invite, 4 = probably invite, 5 = definitely invite. LTI was recorded at three instances during each review: 1) after typical screening (blinded to the SVI), 2) after unblinding to the SVI score, and 3) after viewing the SVI video.

RESULTS

Seventeen reviewers at nine ACGME-accredited residency programs participated. We reviewed 2,219 applications representing 1,424 unique applicants. After unblinding the SVI score, LTI did not change in 2,065 (93.1%), increased in 85 (3.8%) and decreased in 69 (3.1%; p = 0.22). In subgroup analyses, the effect of the SVI on LTI was unchanged by United States Medical Licensing Examination score. However, when examining subgroups of SVI scores, the percentage of applicants in whom the SVI score changed the LTI was significantly different in those that scored in the lower and upper subgroups (p < 0.0001). The SVI video was viewed in 816 (36.8%) applications. Watching the video did not change the LTI in 631 (77.3%); LTI increased in 106 (13.0%) and decreased in 79 (9.7%) applications (p = 0.04).

CONCLUSIONS

The SVI score changed the LTI in 7% of applications. In this group, the score was equally likely to increase or decrease the LTI. Lower SVI scores were more likely to decrease the LTI than higher scores were to increase the LTI. Watching the SVI video was more likely to increase the LTI than to decrease it.

Standardized Video Interviews Do Not Correlate to United States Medical Licensing Examination Step 1 and Step 2 Scores

Introduction

In 2017, the Standardized Video Interview (SVI) was required for applicants to emergency medicine (EM). The SVI contains six questions highlighting professionalism and interpersonal communication skills. The responses were scored (6–30). As it is a new metric, no information is available on correlation between SVI scores and other application data. This study was to determine if a correlation exists between applicants’ United States Medical Licensing Examination (USMLE) and SVI scores. We hypothesized that numeric USMLE Step 1 and Step 2 Clinical Knowledge (CK) scores would not correlate with the SVI score, but that performance on the Step 2 Clinical Skills (CS) portion may correlate with the SVI since both test communication skills.

Methods

Nine EM residency sites participated in the study with data exported from an Electronic Residency Application Service (ERAS®) report. All applicants with both SVI and USMLE scores were included. We studied the correlation between SVI scores and USMLE scores. Predetermined subgroup analysis was performed based on applicants’ USMLE Step 1 and Step 2 CK scores as follows: (≥ 200, 201–220, 221–240, 241–260, >260). We used linear regression, the Kruskal-Wallis test and Mann-Whitney U test for statistical analyses.

Results

1,325 applicants had both Step 1 and SVI scores available, with no correlation between the overall scores (p=0.58) and no correlation between the scores across all Step 1 score ranges, (p=0.29). Both Step 2 CK and SVI scores were available for 1,275 applicants, with no correlation between the overall scores (p=0.56) and no correlation across all ranges, (p=0.10). The USMLE Step 2 CS and SVI scores were available for 1,000 applicants. Four applicants failed the CS test without any correlation to the SVI score (p=0.08).

Conclusion

We found no correlation between the scores on any portion of the USMLE and the SVI; therefore, the SVI provides new information to application screeners.

Cognitive error in an academic emergency department

Background

Medical error is a leading cause of death nationwide. While systems issues have been closely investigated as a contributor to error, little is known about the cognitive factors that contribute to diagnostic error in an emergency department (ED) environment.

Methods

Eight months of patient revisits within 72 h where patients were admitted on their second visit were examined. Fifty-two cases of confirmed error were identified and classified using a modified version of the Australian Patient Safety Foundation classification system for medical errors by a group of trained physicians.

Results

Faulty information processing was the most frequently identified category of error (45% of cases), followed by faulty verification (31%). Faulty knowledge (6%) and faulty information gathering (18%) occurred relatively infrequently. “Misjudging the salience of a finding” and “premature closure” were the individual errors that occurred most frequently (13%).

Conclusions

Despite the complex nature of diagnostic reasoning, cognitive errors of information processing appear to occur at higher rates than other errors, and in a similar pattern to an internal medicine service despite a different clinical environment. Further research is needed to elucidate why these errors occur and how to mitigate them.

ASSESSMENT OF RADIATION DOSE AND EXCESSIVE LIFE-TIME CANCER RISK FROM THE BUNAIR GRANITE, NORTHERN PAKISTAN

Natural radioactivity was measured in Bunair Granite using high purity germanium gamma-ray spectrometer and compared to world's granites and building materials to access its suitability for the construction purpose. Average gamma-activities of 226Ra, 232Th and 40K were found to be 52.41, 58.41 and 1130.12 Bq kg-1, respectively. The Indoor and outdoor radiation indices including excessive life-time cancer risk (ELCR) were calculated. The average indoor ELCR was estimated as 3.49 × 10-3. The average outdoor ELCR was assessed as 0.46 × 10-3. As a basic building material Bunair Granite should be on low propriety. For flooring, facing the buildings and as Table tops, in kitchens and other utilities it is safe.

Blog and Podcast Watch: Orthopedic Emergencies

Introduction

The WestJEM Blog and Podcast Watch presents high quality open-access educational blogs and podcasts in emergency medicine (EM) based on the ongoing ALiEM Approved Instructional Resources (AIR) and AIR-Professional series. Both series critically appraise resources using an objective scoring rubric. This installment of the Blog and Podcast Watch highlights the topic of orthopedic emergencies from the AIR series.

Methods

The AIR series is a continuously building curriculum that follows the Council of Emergency Medicine Residency Directors (CORD) annual testing schedule. For each module, relevant content is collected from the top 50 Social Media Index sites published within the previous 12 months, and scored by eight AIR board members using five equally weighted measurement outcomes: Best Evidence in Emergency Medicine (BEEM) score, accuracy, educational utility, evidence based, and references. Resources scoring ≥30 out of 35 available points receive an AIR label. Resources scoring 27–29 receive an honorable mention label, if the executive board agrees that the post is accurate and educationally valuable.

Results

A total of 87 blog posts and podcasts were evaluated. Key educational pearls from the three AIR posts and the 14 honorable mentions are summarized.

Conclusion

The WestJEM Blog and Podcast Watch series is based on the AIR and AIR-Pro series, which attempts to identify high quality educational content on open-access blogs and podcasts. This series provides an expert-based, post-publication curation of educational social media content for EM clinicians with this installment focusing on orthopedic emergencies.

Audience Response System Facilitates Prediction of Scores on In-Training Examination

Introduction

Audience response systems (ARS) are increasingly popular; however, their contribution to education is not completely clear. Our study found that scores from review quizzes delivered by an ARS correlate with in-training exam (ITE) scores and are viewed positively by residents. This information may be useful in identifying poor performers early so that targeted educational interventions can be made. The objective was to determine if scores on review quizzes delivered by an ARS correlate with ITE scores and to obtain participant feedback on use of the ARS for ITE preparation.

Methods

This was a prospective observational study of emergency medicine (EM) residents at six accredited EM residency programs. Subjects included residents who had taken previous ITEs. Subjects participated in bimonthly review sessions using an ARS. Twelve review quizzes were administered, each consisting of 10 multiple-choice questions. After the ITE, subjects completed an attitudinal survey consisting of six Likert-scale items and one “yes/no” item. We used a mixed linear model to analyze the data, accounting for prior 2012 ITE scores and nesting due to institution.

Results

Among 192 participants, 135 (70.3%) completed the ITE in both 2012 and 2013; we analyzed their data for the first objective. Results from the mixed linear model indicate that the total mean score on the review quizzes was a significant [t(127) = 6.68; p < 0.001] predictor of the 2013 ITE after controlling for the 2012 ITE score. One hundred forty-six (76.0%) participants completed the attitudinal survey; 96% of respondents stated that they would like ARS to be used more often in resident education. Respondents felt the sessions aided in learning (mean 7.7/10), assisted in preparation for the ITE (mean 6.7/10), and helped identify content areas of weakness (mean 7.6/10).

Conclusion

Our results suggest that scores from review quizzes delivered by an audience response system correlate with in-training exam scores and is viewed positively by residents.

Workplace Violence and Harassment Against Emergency Medicine Residents

Introduction

Several studies have shown that workplace violence in the emergency department (ED) is common. Residents may be among the most vulnerable staff, as they have the least experience with these volatile encounters. The goal for this study was to quantify and describe acts of violence against emergency medicine (EM) residents by patients and visitors and to identify perceived barriers to safety.

Methods

This cross-sectional survey study queried EM residents at multiple New York City hospitals. The primary outcome was the incidence of violence experienced by residents while working in the ED. The secondary outcomes were the subtypes of violence experienced by residents, as well as the perceived barriers to safety while at work.

Results

A majority of residents (66%, 78/119) reported experiencing at least one act of physical violence during an ED shift. Nearly all residents (97%, 115/119) experienced verbal harassment, 78% (93/119) had experienced verbal threats, and 52% (62/119) reported sexual harassment. Almost a quarter of residents felt safe “Occasionally,” “Seldom” or “Never” while at work. Patient-based factors most commonly cited as contributory to violence included substance use and psychiatric disease.

Conclusion

Self-reported violence against EM residents appears to be a significant problem. Incidence of violence and patient risk factors are similar to what has been found previously for other ED staff. Understanding the prevalence of workplace violence as well as the related systems, environmental, and patient-based factors is essential for future prevention efforts.

Significant but reasonable radiation exposure from computed tomography-related medical imaging in the ICU

Admission to an intensive care unit (ICU) is associated with increased medical imaging and radiation exposure, yet few studies have estimated the risk of cancer associated with these examinations. The purpose of this study was to review computed tomography (CT) scans performed on patients admitted to two urban academic ICUs, predict their radiation exposure, and calculate their estimated lifetime attributable risk of cancer (LAR). An electronic chart review was performed on all CT scans performed between January 2007 and December 2011. The estimated effective dose of radiation was calculated for each CT, and the LAR for each patient was predicted. Mean radiation exposure was 22.2 ± 25.0 mSv with a mean LAR of 0.1 ± 0.2 % and a median of 0.6 % with a range of <0.001 to 3.4 %. Our cohort received radiation doses higher than recommended by guidelines; however, the critical nature of their admission may have warranted these imaging studies. Estimated risk of cancer in this population was overall low.

Are Gujarati Asian Indians 'older' for their 'vascular age' as compared to their 'Chronological age'?

BACKGROUND

South Asians are known to carry higher burden of cardiovascular diseases when compared with their Caucasian counterparts.

AIM

This study was designed to evaluate whether vascular age is advanced for Gujarati Asian Indians as matched to their chronological age in apparently healthy, asymptomatic population. We have also assessed the contributing risk factors for premature vascular ageing.

DESIGN

It was cross-sectional study of 2483 individuals of Gujarat state in Western India having no past or present history of major illness including cardiovascular diseases.

METHOD

The vascular age of the population was calculated using Framingham vascular age calculator. A relationship between risk factor prevalence and vascular ageing was evaluated using univariate analysis of variance.

RESULTS

The mean chronological age of the study population was 46.8 (±10.35) years whereas mean vascular age was 53.34 (±16.05) years, and the difference (6.54±9.5) between both was statistically significant (P < 0.0001). Contributory risk factors for advanced vascular age apart from chronological age (75.4%) and male gender (66.2%) were the presence of dyslipidemia (60.4%) hypertension (57.34%) and increased waist circumference (WC) (male 39.7%, female 29%). Results of regression analysis showed that vascular age progression was highly associated with blood pressure (19.9, 95% CI: 14.34-27.63), followed by smoking (15.23, 95% CI: 8.4-27.59), and blood sugar (12.97, 95% CI: 3.48-48.25).

CONCLUSION

The Gujarati Asian Indians are subjected to premature vascular ageing and henceforth routine screening for vascular age and risk factors prevalence is strongly advocated in this ethnic group.

The M694V mutation in Armenian-Americans: a 10-year retrospective study of MEFV mutation testing for familial Mediterranean fever at UCLA

Familial Mediterranean fever (FMF), inherited in an autosomal recessive manner, is a systemic auto-inflammatory disorder characterized by recurrent attacks of fever with peritonitis, pleuritis, synovitis and erysipeloid rash. The marenostrin-encoding fever (MEFV) gene, located on chromosome 16p13.3, is the only gene in which mutations are currently known to cause FMF. To correlate specific genotypes with adverse phenotypes of affected populations residing in the Western United States, a retrospective case series review was conducted of all MEFV gene mutation testing completed at UCLA Clinical Molecular Diagnostic Laboratory between February 2002 and February 2012, followed by clinical chart review of all subjects who either have a single or double mutation. All 12 common mutations in the MEFV gene were analyzed and the M694V variant was found to be associated with an adverse FMF clinical outcome in the Armenian-American population, manifested by earlier onset of disease, increased severity of disease, and renal amyloidosis.

Difficulties with gum elastic bougie intubation in an academic emergency department

BACKGROUND

The difficulties with gum elastic bougie (GEB) use in the emergency department (ED) have never been studied prospectively.

OBJECTIVES

To determine the most common difficulties associated with endotracheal intubation using a GEB in the ED.

METHODS

We conducted a prospective, observational study of GEB practices in our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000 patients. Laryngoscopists performing a GEB-assisted intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), reason for GEB use, and problems encountered. Data were analyzed using standard statistical methods and 95% confidence intervals.

RESULTS

A GEB was used for 88 patients. The overall success rate was 70/88 (79.6%; 95% confidence interval [CI] 71.1-88.0%). The GEB failure rate of the first laryngoscopist was 25/88 (28.4%; 95% CI 21.0-40.3%), with the two most common reasons being: inability to insert the bougie past the hypopharynx in 13 (52%; 95% CI 32.4-71.6%) and inability to pass the endotracheal tube over the bougie in six (24%; 95% CI 7.3-40.7).

CONCLUSIONS

The GEB is a helpful rescue airway device, but emergency care providers should be aware that failure rates are relatively high at a teaching institution.

Removal of Co2+ ions from aqueous solution by cation exchange sorption onto NiO

Batch adsorption technique was used to study the adsorption of cobalt on NiO. The aim of this work was to examine the effect of pH, concentration and temperature on the ion exchange removal of Co2+ from aqueous solution by the NiO surface. We used Langmuir model to interpret the adsorption data. The Kurbatov-type plots were tested to determine the adsorption mechanism. The kinetics of Co2+ adsorption on NiO was best described by film diffusion model. A well-known thermodynamic equation was used to assess the enthalpy and entropy of the system. The thermodynamic data were indicative of the spontaneous nature of the endothermic sorption process of Co2+ onto the NiO.

Chromium (III) removal by weak acid exchanger Amberlite IRC-50 (Na)

Chromium (III) sorption on a weakly macroporous cation exchanger Amberlite IRC-50 (Na) is studied as a function of time and temperature. The rate constant values for chromium (III) sorption are calculated both for film and particle diffusion processes. The temperature is found to have a positive effect on both the diffusional processes. The high values of energy of activation confirm the particle diffusional nature of the process. The pH changes in the system show a competition between the Cr(OH)(2+) and H(+) ions for the exchange sites of the adsorbent. Equilibrium data are explained with the help of Langmuir equation. Various thermodynamic parameters (DeltaH degrees , DeltaS degrees and DeltaG degrees) from chromium (III) exchange on the resin are calculated.

Short-term prognosis of stroke among patients diagnosed in the emergency department with a transient ischemic attack

STUDY OBJECTIVE

It is now clear that transient ischemic attacks and strokes are different manifestations of the same disease and transient ischemic attacks are often warning signs of an impending stroke. Unfortunately, it is unclear when the next event will occur in an individual patient. It is critical for emergency physicians to know what the true risk of stroke is for patients who present to the emergency department (ED) with a transient ischemic attack and a normal neurologic examination result. We perform an evidence-based emergency medicine shortcut review of the short-term outcome of stroke among patients diagnosed in the ED with a transient ischemic attack.

METHODS

We searched PubMed for articles that studied patients with transient ischemic attack and reported their risk of stroke up to 30 days. We used standard criteria to appraise the quality of prognostic studies.

RESULTS

Eight studies met the inclusion criteria; 5 were conducted prospectively and 3 had a retrospective design. Of the 5 prospective studies, only 2 enrolled patients from the ED. The 48-hour risk of stroke after transient ischemic attack ranged from 1.4% to 9.9% and the 7-day risk ranged from 3.8% to 12.8%. However, the 2 ED-based studies suggest that the short-term risk of having a stroke after a transient ischemic attack in the next 48 hours is approximately 3% to 5% and during the next week is 4% to 7%.

CONCLUSION

According to studies assessing the short-term prognosis of patients diagnosed with transient ischemic attack in the ED, approximately 1 in 20 patients will have a stroke during the following 48 hours.

How sensitive is the synovial fluid white blood cell count in diagnosing septic arthritis?

OBJECTIVE

This study was conducted to determine the sensitivity of the current standard for synovial fluid leukocytosis analysis in diagnosing infectious arthritis or a septic joint. How accurate is the standard synovial fluid white blood cell (WBC) cutoff of 50,000 WBC/mm3 to rule out septic arthritis?

METHODS

We conducted a retrospective study at an urban tertiary care medical center with 50,000 adult emergency department visits per year. The study population consisted of patients with infectious arthritis confirmed by synovial fluid culture growth of a pathogenic organism. The study period lasted from January 1996 to December 2002. Extracted data included synovial fluid leukocyte count, Gram's stain, culture, past medical history, and discharge diagnosis. Fisher exact test was used to compare proportions. Sensitivity and means were calculated with 95% confidence intervals (CI).

RESULTS

There were 49 culture-positive synovial fluid aspirates in the 6-year study period. Nineteen (39%) of 49 patients (95% CI, 25%-52%) had a synovial WBC of less than 50,000/mm3 and 30 (61%) of 49 patients (95% CI, 48%-75%) had a synovial WBC of more than 50,000/mm3. The sensitivity of the 50,000 synovial WBC/mm3 cutoff was 61% (95% CI, 48%-75%). Twenty-seven (55%) of 49 patients had a negative Gram's stain (95% CI, 41%-69%) and 15 (56%) of 27 patients (95% CI, 37%-74%) with negative Gram's stain had a synovial WBC of less than 50,000/mm3.

CONCLUSION

A synovial fluid WBC cutoff of 50,000/mm3 lacks the sensitivity required to be clinically useful in ruling out infectious arthritis.

Rhabdomyolysis

Rhabdomyolysis is a syndrome involving the breakdown of skeletal muscle causing myoglobin and other intracellular proteins and electrolytes to leak into the circulation. The development of rhabdomyolysis is associated with a wide variety of diseases, injuries, medications and toxins. While the exact mechanisms responsible for all the causes are not fully understood, it is clear that muscle damage can occur from direct injury or by metabolic inequalities between energy consumption and energy production. Rhabdomyolysis is diagnosed by elevations in serum creatine phosphokinase (CPK), and while there is no established serum level cut-off, many clinicians use five times the upper limit of normal ( approximately 1000 U/l). Rhabdomyolysis can be complicated by acute renal failure (occurring in 4%-33% of patients), compartment syndrome, cardiac dysrhythmias via electrolyte abnormalities, and disseminated intravascular coagulopathy. The mainstay of treatment is hospitalisation with aggressive intravenous fluid (IVF) resuscitation with the correction/prevention of electrolyte abnormalities. There are additional adjunctive therapies to IVF, such as alkalinisation of the urine with sodium bicarbonate, diuretic therapy or combinations of both; however the lack of large randomised control studies concerning the benefits of these treatments makes it difficult to make strong recommendations for or against their use in the treatment of rhabdomyolysis. Regardless of these controversies, the overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common. Irrespective of the cause of rhabdomyolysis the mortality rate may still be as high as 8%. This is a comprehensive review of the pathophysiology, diagnosis, complications and treatment options for rhabdomyolysis.

Predicting difficult and traumatic lumbar punctures

OBJECTIVE

The objective of this study is to determine if visual and tactile inspection of the spine is useful in the prediction of a difficult or traumatic lumbar puncture (LP).

DESIGN

This was a prospective, observational, cohort study conducted in the emergency department (ED) on patients who were undergoing an LP. Physicians prospectively completed a structured data form that included information about the patient, number of prior LPs performed, their assessment of the LP difficulty, and the number of needlesticks required. A "difficult" LP and a "traumatic" tap were defined a priori. Chi2, t tests, and regression were used as appropriate; an independent statistician performed the statistical analysis.

SETTING

The study was conducted at an urban university teaching hospital with an annual ED census of approximately 48,000 patients between November 1, 2002, and June 1, 2003.

PATIENTS

The study population included a convenience sample of patients undergoing LP in the ED.

RESULTS

Of the 148 patients enrolled, LP was difficult in 47 (32%) patients and traumatic in 23 (16%) patients. The percentage of patients that did not have a visible spine was significantly higher in the difficult and traumatic groups (P < .05). Among patients where the physician was unable to visualize the spine, there were significantly more difficult LPs (P < .05).

CONCLUSION

It may be possible to predict which patients will have difficult or traumatic LPs before performing the procedure. Simple bedside assessments of spine visibility and palpability may assist in planning the approach to an LP in patients.