Dave Milzman

Thoracic impedance vs chest radiograph to diagnose acute pulmonary edema in the ED

OBJECTIVE We sought to investigate the relationship between thoracic impedance (Zo) and pulmonary edema on chest radiography in patients presenting to the emergency department (ED) with signs and symptoms of acute decompensated heart failure (ADHF). DESIGN This was a prospective, blinded convenience sample of patients with signs and symptoms of ADHF who underwent measurement of Zo with concomitant chest radiography. Attending physicians blinded to the Zo values interpreted the radiographs, categorizing the severity of pulmonary edema as normal (NL), cephalization (CZ), interstitial edema (IE), or alveolar edema (AE). Intergroup comparisons were analyzed with a 2-way analysis of variance (ANOVA), with P < .05 considered statistically significant and reported using 95% confidence intervals (CIs). SETTING We enrolled patients (> or =18 years) presenting to a tertiary care medical center ED with signs and symptoms consistent with ADHF. RESULTS A total of 203 patients were enrolled, with 27 (14%) excluded because of coexisting pulmonary diseases. The mean Zo values were inversely related to the 4 varying degrees of radiographic pulmonary vascular congestion as follows: NL, 25.6 (95% CI, 22.9-28.3); CZ, 20.8 (95% CI, 18.1-23.5); IE, 18.0 (95% CI, 16.3-19.7); and with AE, 14.5 (95% CI, 12.8-16.2) (ANOVA, P < .04). A Zo less than 19.0 ohms had 90% sensitivity and 94% specificity (likelihood ratio [LR], - 0.1; LR + 15) for identifying radiographic findings consistent with pulmonary edema. Females had an increased mean Zo value compared to males (P < .03). CONCLUSION The Zo value obtained via thoracic bioimpedance monitoring accurately predicts the presence and severity of pulmonary edema found on initial chest radiograph in patients suspected of ADHF.

Injury patterns in recreational alpine skiing and snowboarding at a mountainside clinic.

OBJECTIVE The purpose of this study was to examine the demographic and injury characteristics of skiing and snowboarding at a mountainside clinic. METHODS Prospectively collected data of all acutely injured patients at the Big Sky Medical Clinic at the base of Big Sky Ski Area in the Northern Rocky Mountains were reviewed. A total of 1593 patients filled out the study questionnaire during the 1995-2000 and 2009-2010 ski seasons. Injury patterns by sport, demographics, and skill level were analyzed and compared over time. RESULTS The mean overall age was 32.9 ± 14.9 years, 35.4 ± 15.2 for skiers and 23.6 ± 9.5 for snowboarders (P < .01). The knee accounted for 43% of all skiing injuries, the shoulder 12%, and the thumb 8%. The wrist accounted for 18% of all snowboarding injuries, the shoulders 14%, and the ankle and knee each 13%. Beginner snowboarders were more likely to present with wrist injuries compared with intermediate (P = .04) and advanced snowboarders (P < .01). Demographic and injury patterns did not significantly change over time. CONCLUSIONS At this mountainside clinic, the most frequent ski injuries are to the knee and shoulder, regardless of skill level. Beginning snowboarders most frequently injure their wrists whereas shoulder injuries remain frequent at all skill levels. Knowledge of these injury patterns may help manage patients who present for medical care in the prehospital setting as well as help in designing targeted educational tools for injury prevention.

The Role of the Emergency Physician for Injured Geriatric Patient Care in the ED

The rapidly aging population is now shifting the focus of healthcare. As the population lives longer, a greater percentage of individuals are living longer, more active, and subsequently at more of a risk to suffer from a traumatic injury. This means that more older persons are at risk to fall down and fracture a hip and suffer from a subdural hematoma and more at risk to be struck in a crosswalk and suffer from multiple trauma. Injuries in the geriatric population presenting to the emergency department (ED) are undergoing a change in presentations and complexity. Geriatric trauma is increasing both in absolute number and proportion of annual trauma admissions, with admissions in level I and II trauma centers up from 23% in 2003 to 30% in 2009 [1]. The geriatric trauma patient is three to five times more likely to die from trauma than a younger patient who sustains a similar mechanism of injury [2, 3].