Christy L. McCowan

Refractory delirium tremens treated with propofol: A case series

Delirium tremens, the most serious manifestation of alcohol withdrawal, occurs in approximately 5% of hospitalized alcoholics and has a mortality rate approaching 15%. Patients with delirium tremens are usually treated in an intensive care unit in which benzodiazepines form the cornerstone of therapy. In this report, we describe four patients who proved refractory to high doses of benzodiazepines and were successfully treated with a propofol infusion.

An analysis of skiing and snowboarding injuries on Utah slopes.

BACKGROUND Injuries sustained while skiing or snowboarding are commonly encountered in emergency departments near winter resorts. The purpose of this study is to identify and compare the types of injuries likely to be found in the skier or snowboarder patient. An additional goal of this study is to provide a description of the demographics and hospitalizations for these patients. METHODS A retrospective cohort study consisting of patients treated for skiing- or snowboarding-related injuries was performed at the University of Utah Medical center. All emergency department visits were captured: walk-ins and emergency medical service transports (ground and air). Seven hundred ninety-four skiing and 348 snowboarding-related cases were identified for a total of 1,142. Cases that occurred within 2001/2002 to 2005/2006 seasons were included in the study. Injuries were classified according to the International Classification of Diseases-9th Revision system and categorized by body location and specific type of injury. Outputs for this study include the chi test using the skiers as the control group due to size, with risk odds ratios comparing snowboarders to skiers. A p value of <0.05 was considered significant. RESULTS Patients injured while skiing and snowboarding were predominantly men, representing 70.0% of injured skiers and 87.6% of injured snowboarders. The mean age for skiers was 41 (SD = 16), whereas the mean age for snowboarders was 23 (SD = 8). High percentages of patients among both groups had suffered injury to the head, which was more common in snowboarders when compared with skiers (27.3% vs. 20.4%, p = 0.010). Despite this fact, skiers tended to have slightly higher percentages of Glasgow Coma Scores in the moderate to severe range and accounted for all fatalities secondary to head injury (8 of 9 fatalities). The single snowboarder fatality was not caused by head injury but rather pneumothorax. Injuries to the head that were more common in skiers were fractures to the facial bones (5.2% vs. 1.4%, p = 0.003) and facial lacerations (5.8% vs. 2.9%, p = 0.035). Skiers were more likely to sustain injuries to the lower extremities (51.3% vs. 26.2%, p < 0.001), whereas snowboarders commonly had injuries to the abdomen and its organs (22.4% vs. 11.2%, p < 0.001). A considerable amount of snowboarders had injuries to the spleen (11.2%), liver (3.7%), and kidney (2.2%). Injuries to the spine were common in both groups but more in snowboarders (20.7% vs. 13.4%, p = 0.002). On an average, skiers spent 3.4 days in the hospital (SD = 3), a day longer than snowboarders who averaged 2.4 (SD = 2). Skiers were more frequently admitted to the floor or the operating room, whereas snowboarders were more often admitted to the intensive care unit. CONCLUSION Patients injured while skiing or snowboarding are predominantly men, and participants in both sports are at risk for sustaining major injuries. The types of injuries differ and are dependent on the sport. An awareness of these differences will help skiers and snowboarders minimize their risk of injury by altering their riding strategies and by choosing appropriate protective equipment.

Outcomes of pediatric trauma patients transported from rural and urban scenes

OBJECTIVES Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes. METHODS Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records. RESULTS Total mileage, flight times, and scene times were significantly longer for rural flights (P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients. CONCLUSIONS Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.

Outcomes of Blunt Trauma Victims Transported by HEMS from Rural and Urban Scenes

Objective. Mortality differences exist between victims of urban andrural trauma; however, it is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, length of hospital stay, anddischarge status of adult blunt trauma victims transported by HEMS from rural andurban scenes to regional trauma centers. Methods. Retrospective review of all adult (age ≥ 15) HEMS transports in 2001; 271 urban and141 rural blunt trauma patients were identified from HEMS transport records andthe trauma registries at three level one trauma centers. Demographic data, scene andhospital interventions, as well as discharge status of the two groups were examined. Results. Total mileage [27 ± 12 vs. 119 ± 64, p < 0.001], total flight times (minutes) [30 ± 10 vs. 79 ± 40, p < 0.001], andscene times (minutes) [16 ± 8 vs. 21 ± 14, p < 0.001] were significantly longer for rural flights. There were no significant differences between the groups with regard to age, gender, receiving hospital, andinitial HEMS vitals. Injury Severity Score, ICU length of stay (LOS), total hospital LOS, andhospital mortality did not differ between the two groups. After controlling for age, gender, andISS, there were no significant mortality differences between the two groups (p = 0.074). Conclusions. Despite longer flight andscene times for rural patients, adjusted in-hospital mortality rates were similar for patients transported from urban andrural scenes. Factors prior to HEMS arrival may contribute to increased mortality rates of rural blunt trauma victims documented nationally.

Amyand hernia: a case of an unusual inguinal herniace.

Amyand hernia, named for the first person to describe an inguinal hernia containing the vermiform appendix, is an uncommon variant of an inguinal hernia. Presence of the appendix in the sac complicates the management of inguinal hernias. The appendix may be more prone to rupture when contained within a hernia sac, and herniation of an inflamed appendix into the scrotum can mimic an acute scrotum. A 50-year-old man presented with right lower quadrant abdominal pain associated with chills and anorexia. Physical examination revealed right lower quadrant tenderness and a right inguinal mass without associated skin changes. Laboratories were normal. A plain abdominal computed tomography scan for acute appendicitis showed an indirect right inguinal hernia with the appendix contained within the sac, which was incarcerated. Surgical consultation was obtained. The patient taken to the operating room, and his appendix was removed. The hernia was coincidentally repaired, and the patient was discharged soon thereafter. In cases suggestive of acute appendicitis complicating an inguinal hernia, the diagnosis of this unusual variant must be considered.

Scene Transport of Pediatric Patients Injured at Winter Resorts

Objective. To examine the characteristics of pediatric patients (age ≤16 years) injured at winter resort scenes andtransported by helicopter emergency medical services (HEMS) or ground EMS (GEMS) ambulance services to regional trauma centers. Methods. Between 1997 and2001, a total of 119 patients (GEMS = 69; HEMS = 50) were identified from trauma registries andHEMS transport records. Demographic data, initial vital signs, hospital interventions, anddischarge status of the two groups were examined. Results. The distributions of gender, initial vital signs, Injury Severity Score (ISS; either ≤ or > 15), intensive care unit (ICU) length of stay (LOS), total hospital LOS, andhome discharge status were similar between the two groups (p ≥ 0.05). Patients transported by HEMS were older (14 ± 2 vs. 10 ± 4, p < 0.001), less likely to be admitted to the hospital (73% vs. 98.5%; p < 0.001), andmore likely to have multiple injuries [13 (27%) vs. 8 (11.6%), p ≤ 0.032]. The GEMS patients had a higher rate of isolated extremity [33 (80.5%) vs. 8 (19.5%)] andthoracoabdominal [11 (73.3%) vs. 4 (26.7%)] injuries. The high orthopedic injury rate in the GEMS patients contributed to a higher rate of surgery in this group (45% vs. 24%, p ≤ 0.028). Regardless of transport mode, patients requiring immediate interventions (intubation, chest tube placement, or blood product administration) had either a depressed level of consciousness (GCS = 12) on emergency department arrival or thoracoabdominal injuries. No deaths were recorded. Conclusions. Patients transported by HEMS andGEMS had similar hospital characteristics but different injury patterns. A prospective study examining the initial triage of pediatric patients injured at winter resorts would help to determine which subset of patients are best served by HEMS transport.