Gil Z. Shlamovitz

How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients

OBJECTIVES Our goal was to evaluate the utility of the pelvic ring stability examination for detection of mechanically unstable pelvic fractures in blunt trauma patients. METHODS Retrospective chart review. RESULTS We enrolled 1,502 consecutive blunt trauma patients and found 115 patients with pelvic fractures including 34 patients with unstable pelvic fractures (Tile classification B and C). Unstable pelvic ring on physical examination had a sensitivity and specificity of 8% (95% CI 4-14) and 99% (95% CI 99-100), respectively, for detection of any pelvic fracture and 26% (95% CI 15-43) and 99.9% (95% 99-100), respectively, for detection of mechanically unstable pelvic fractures. The sensitivity and specificity of pelvic pain or tenderness in patients with Glasgow Coma Scale >13 were 74% (95% CI 64-82) and 97% (95% CI 96-98), respectively for diagnosing any pelvic fractures, and 100% (95% CI 85-100) and 93% (95% CI 92-95), respectively for diagnosing of mechanically unstable pelvic fractures. The sensitivity and specificity of the presence of pelvic deformity were 30% (95% CI 22-39) and 98% (95% CI 98-99), respectively for detection of any pelvic fracture and 55% (95% CI 38-70) and 97% (95% CI 96-98), respectively for detection of mechanically unstable pelvic fractures. CONCLUSIONS The presence of either pelvic deformity or unstable pelvic ring on physical examination has poor sensitivity for detection of mechanically unstable pelvic fractures in blunt trauma patients. Our study suggests that blunt trauma patients with Glasgow Coma Scale >13 and without pelvic pain or tenderness are unlikely to suffer an unstable pelvic fracture. A prospective study is needed to determine whether a set of clinical criteria can safely detect or exclude the presence of an unstable pelvic fracture.

Lack of evidence to support routine digital rectal examination in pediatric trauma patients.

Background: Current advanced trauma life support guidelines recommend that a digital rectal examination (DRE) should be performed as part of the initial evaluation of all trauma patients. Our primary goal was to estimate the test characteristics of the DRE in pediatric patients for the following injuries: (1) spinal cord injuries, (2) bowel injuries, (3) rectal injuries, (4) pelvic fractures, and (5) urethral disruptions. Methods: We conducted a nonconcurrent, observational, chart review study of a consecutive series of pediatric trauma patients. We enrolled all patients younger than 18 years seen in our ED from January 2003 to February 2005, for whom the trauma team was activated and who had a documented DRE. For each patient, we reviewed all available clinical documents in a computerized medical record system to identify the DRE findings followed by review of radiological reports, operative reports, and discharge summaries to identify specific injuries. Results: Two hundred thirteen patients met our selection criteria and were included in the analysis. We identified 3 patients with spinal cord injury (1% prevalence), 13 patients with bowel injury (6%), 5 patients with rectal injury (2%), 12 patients with a pelvic fracture (6%), and 1 patient with urethral disruption (0.5%). The DRE failed to diagnose (false-negative rate) 66% of spinal cord injuries, 100% of bowel injuries, 100% of rectal wall injuries, 100% of pelvic fractures, and 100% of urethral disruption injuries. Conclusions: The DRE has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the DRE should not be routinely used in pediatric trauma patients.

Intravenous ketamine in a dissociating dose as a temporizing measure to avoid mechanical ventilation in adult patient with severe asthma exacerbation.

BACKGROUND Patients experiencing severe asthma exacerbations occasionally deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation in this setting exposes the patients to substantial iatrogenic risk and should be avoided if at all possible. OBJECTIVES To describe the use of intravenous ketamine in acute asthma exacerbation. CASE REPORT We present a case of severe asthma exacerbation in an adult female patient who failed to improve with standard therapies, but promptly improved with the administration of intravenous ketamine (0.75 mg/kg i.v. bolus followed by continuous drip of 0.15 mg/kg/h). SUMMARY This case suggests that intravenous ketamine given in a dissociative dose may be an effective temporizing measure to avoid mechanical ventilation in adult patients with severe asthma exacerbations.

In Vitro Ultrasound Augmented Clot Dissolution—What is the Optimal Timing of Ultrasound Application?

The mechanism of ultrasound augmentation of pharmacological thrombolysis is yet unknown. The goal of this study is to find the best timing regimen for in-vitro ultrasound augmented clot dissolution by streptokinase, heparin and their combination. Blood clots from 4 donors were cut into 200–400 mg sections and randomized to no treatment with ultrasound; pre-treatment with ultrasound (before immersion); early treatment with ultrasound; or late treatment with ultrasound. Clots were placed in tubes containing either saline; heparin; streptokinase or streptokinase +heparin. All groups showed significant weight reduction (p < 0.001). Using the one way ANOVA test, we showed that ultrasound application resulted in a significantly higher rate of clots dissolution (p < 0.05) than without ultrasound in all of the solutions tested. We found no statistically significant difference between the three ultrasound regimens tested. In conclusion, in our in-vitro model, no single ultrasound timing schedule was found to provide better clot dissolution than the other schedules. This finding may suggest an additive effect between the ultrasound and the different solutions rather than a synergistic effect.

Diagnostic errors related to acute abdominal pain in the emergency department

Objective Diagnostic errors in the emergency department (ED) are harmful and costly. We reviewed a selected high-risk cohort of patients presenting to the ED with abdominal pain to evaluate for possible diagnostic errors and associated process breakdowns. Design We conducted a retrospective chart review of ED patients >18 years at an urban academic hospital. A computerised ‘trigger’ algorithm identified patients possibly at high risk for diagnostic errors to facilitate selective record reviews. The trigger determined patients to be at high risk because they: (1) presented to the ED with abdominal pain, and were discharged home and (2) had a return ED visit within 10 days that led to a hospitalisation. Diagnostic errors were defined as missed opportunities to make a correct or timely diagnosis based on the evidence available during the first ED visit, regardless of patient harm, and included errors that involved both ED and non-ED providers. Errors were determined by two independent record reviewers followed by team consensus in cases of disagreement. Results Diagnostic errors occurred in 35 of 100 high-risk cases. Over two-thirds had breakdowns involving the patient–provider encounter (most commonly history-taking or ordering additional tests) and/or follow-up and tracking of diagnostic information (most commonly follow-up of abnormal test results). The most frequently missed diagnoses were gallbladder pathology (n=10) and urinary infections (n=5). Conclusions Diagnostic process breakdowns in ED patients with abdominal pain most commonly involved history-taking, ordering insufficient tests in the patient–provider encounter and problems with follow-up of abnormal test results.