C. Eric McCoy

Guidelines for Field Triage of Injured Patients: In conjunction with the Morbidity and Mortality Weekly Report published by the Center for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) has published significant data and trends related to the national public health burden associated with trauma and injury. In the United States (U.S.), injury is the leading cause of death for persons aged 1–44 years. In 2008, approximately 30 million injuries resulted in an emergency department (ED) evaluation; 5.4 million (18%) of these patients were transported by Emergency Medical Services (EMS).1 EMS providers determine the severity of injury and begin initial management at the scene. The decisions to transport injured patients to the appropriate hospital are made through a process known as “field triage.” Since 1986, the American College of Surgeons Committee on Trauma (ACS-COT) has provided guidance for the field triage process though its “Field Triage Decision Scheme.” In 2005, the CDC, with financial support from the National Highway Traffic Safety Administration (NHTSA), collaborated with ASC-COT to convene the initial meeting of the National Expert Panel on Field Triage (the Panel) to revise the decision scheme. This revised version was published in 2006 by ASC-COT, and in 2009 the CDC published a detailed description of the scientific rational for revising the field triage criteria entitled, “Guidelines for Field Triage of Injured Patients.”2–3 In 2011, the CDC reconvened the Panel to review the 2006 Guidelines and recommend any needed changes. We present the methodology, findings and updated guidelines from the Morbidity & Mortality Weekly Report (MMWR) from the 2011 Panel along with commentary on the burden of injury in the U.S., and the role emergency physicians have in impacting morbidity and mortality at the population level.

Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center

STUDY OBJECTIVE We determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban Level I trauma center. METHODS We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a Level I trauma center during a 14-year period (1996 to 2009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban Level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding 5 hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated with multivariate logistic regression. RESULTS There were 19,167 trauma patients available for analysis, with 865 (4.5%) deaths; 16,170 (84%) injuries were blunt, with 596 (3.7%) deaths, and 2,997 (16%) were penetrating, with 269 (9%) deaths. Mean age and sex for blunt and penetrating trauma were 34.5 years (68% men) and 28.1 years (90% men), respectively. Of those with Injury Severity Score less than or equal to 15, 0.4% died, and 26.1% of those with a score greater than 15 died. We analyzed the relationship of scene time and transport time with mortality among patients with Injury Severity Score greater than 15, controlling for age, sex, Injury Severity Score, and Revised Trauma Score. On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes (odds ratio [OR] 2.90; 95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were likewise not associated with increased odds of mortality in penetrating trauma cases; OR for transport time greater than or equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR for transport time 10 to 19 minutes was 0.64 (95% CI 0.35 to 1.15). For patients with blunt trauma, we did not observe any association between scene or transport times and increased odds of mortality. CONCLUSION In this analysis of patients presenting to an urban Level I trauma center during a 14-year period, we observed increased odds of mortality among patients with penetrating trauma if scene time was greater than 20 minutes. We did not observe associations between increased odds of mortality and out-of-hospital times in blunt trauma victims. These findings should be validated in an external data set.

Understanding the Intention-to-treat Principle in Randomized Controlled Trials

Clinicians, institutions, and policy makers use results from randomized controlled trials to make decisions regarding therapeutic interventions for their patients and populations. Knowing the effect the intervention has on patients in clinical trials is critical for making both individual patient as well as population-based decisions. However, patients in clinical trials do not always adhere to the protocol. Excluding patients from the analysis who violated the research protocol (did not get their intended treatment) can have significant implications that impact the results and analysis of a study. Intention-to-treat analysis is a method for analyzing results in a prospective randomized study where all participants who are randomized are included in the statistical analysis and analyzed according to the group they were originally assigned, regardless of what treatment (if any) they received. This method allows the investigator (or consumer of the medical literature) to draw accurate (unbiased) conclusions regarding the effectiveness of an intervention. This method preserves the benefits of randomization, which cannot be assumed when using other methods of analysis. The risk of bias is increased whenever treatment groups are not analyzed according to the group to which they were originally assigned. If an intervention is truly effective (truth), an intention-to-treat analysis will provide an unbiased estimate of the efficacy of the intervention at the level of adherence in the study. This article will review the “intention-to-treat” principle and its converse, “per-protocol” analysis, and illustrate how using the wrong method of analysis can lead to a significantly biased assessment of the effectiveness of an intervention.

Correlation of Simulation Examination to Written Test Scores for Advanced Cardiac Life Support Testing: Prospective Cohort Study

Introduction Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been used in many specialties as a training resource as well as an evaluative tool. There are no data to our knowledge that compare simulation examination scores with written test scores for ACLS courses. Objective To compare and correlate a novel high-fidelity simulation-based evaluation with traditional written testing for senior medical students in an ACLS course. Methods We performed a prospective cohort study to determine the correlation between simulation-based evaluation and traditional written testing in a medical school simulation center. Students were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario. Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome was comparison of simulation-based vs. written outcome scores. Results The composite average score on the written evaluation was substantially higher (93.6%) than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6–14.0%], p<0.00005). We found a statistically significant moderate correlation between simulation scenario test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new evaluation method. Conclusion Simulation-based ACLS evaluation methods correlate with traditional written testing and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and challenging testing method, as students scored higher on written evaluation methods compared to simulation.

Creation of a realistic model for removal of a metallic corneal foreign body for less than

Metallic corneal foreign bodies (MCFBs) are one of the most common causes of ocular injury presenting to the emergency department. Delays in removal, or forceful attempts to remove the MCFB can lead to infection, further injury to the eye, and worsening of vision. In order to prevent these underlying complications, it is imperative for the medical provider to properly master this technique. As current trends in simulation become more focused on patient safety, task-trainers can provide an invaluable learning experience for residents, medical students and physicians. Models made from bovine eyes, agar plates, gelatin, and corneas created from glass and paraffin wax have been previously been created. One study also used a rubber glove filled with water to simulate intraocular measurement with a Tonopen. However the use of corneas created from ballistics gel for MCFB removal and intraocular pressure measurement has not been studied. We propose a realistic, sustainable, cost-effective MCFB task-trainer to introduce the fundamental skills required for MCFB removal and measurement of intraocular pressure with a Tonopen. A pilot survey study performed on medical students and emergency medicine resident physicians showed an increase in comfort levels performing both MCFB removal and measurement of intraocular pressure with a Tonopen after using this task-trainer.

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Pregnancy can obscure signs and symptoms of acute appendicitis, making diagnosis challenging. Furthermore, avoiding radiation-based imaging due to fetal risk limits the diagnostic options clinicians have. Once appendicitis has been diagnosed, performing appendectomies has been the more commonly accepted course of action, but conservative, nonsurgical approaches are now being considered. This report describes the latest recommendations from different fields and organizations for the diagnosis and treatment of appendicitis during pregnancy.

Latest Considerations in Diagnosis and Treatment of Appendicitis During Pregnancy

A 38-year-old female seasoned marathon runner presented to the emergency department (ED) with increasing right lower extremity pain after running two mid-distance races in one weekend. The patient had previously run many two-day races and longer distances, but recently had gained weight and had not been training. This case report details her presenting symptoms, evaluation, review of the literature, and treatment with attention to the factors that led to the development of her pathologies.

Compartment Syndrome with Rhabdomyolysis in a Marathon Runner

Blunt cardiac injury encompasses multiple injuries, including contusion, acute valvular disorders, and chamber rupture. Blunt traumatic cardiac rupture is a very rare occurrence accounting for 0.5% of blunt trauma cases with a very high mortality rate. Coexisting pericardial rupture in patients with cardiac rupture obscures the diagnosis and contributes to mortality. False negative pericardial ultrasound secondary to a concomitant pericardial laceration and subsequent decompression of the cardiac hemorrhage into the ipsilateral pleural space is extremely rare and has only been recently described in the literature. This image depicts a case of traumatic right ventrictular rupture from blunt cardiac injury and highlights the importance of considering an underlying cardiac injury in the presence of a negative FAST pericardial window in patients with a traumatic hemothorax.

Traumatic Right Ventricular Rupture after Blunt Cardiac Injury: CT Diagnosis after False Negative Pericardial Window on FAST Due to Concomitant Pericardial Rupture

The objective was to evaluate the comparative effectiveness of telesimulation versus standard simulation in teaching medical students the management of critically ill patients

Prospective Randomized Crossover Study of Telesimulation Versus Standard Simulation for Teaching Medical Students the Management of Critically Ill Patients.

Leriche syndrome, also referred to as aortoiliac occlusive disease, has been described as a triad of claudication, impotence and decreased femoral pulses.1 The syndrome results from thrombotic aortoiliac occlusion and was first described by a French surgeon, Rene Leriche, in 1940.1–2 The disease most commonly occurs in men, and risk factors include hypertension, diabetes, hyperlipidemia, and smoking.3 Advanced diagnostic imaging techniques such as abdominal ultrasonography and computed tomography (CT) angiography assist the clinician in confirming the diagnosis. Treatment is primarily surgical and consists of aortoiliac endarterectomy and aortobifemoral bypass. Alternative procedures described are percutaneous transluminal angioplasty with stenting, and axillofemoral bypass.4–5