Richard Sinert

Exercise-induced rhabdomyolysis.

STUDY OBJECTIVE To describe the syndrome of exercise-induced rhabdomyolysis and to investigate the relation between exercise-induced rhabdomyolysis and the development of acute renal failure. DESIGN Retrospective chart analysis on all patients with a discharge diagnosis of rhabdomyolysis from January 1988 to January 1993. SETTING An urban tertiary care center with 225,000 annual emergency department visits. TYPE OF PARTICIPANTS Thirty-five patients met the inclusion criteria for exercise-induced rhabdomyolysis: a history of strenuous exercise, creatine phosphokinase level more than 500, and urine dipstick positive for blood without hematuria. We excluded patients with a history of trauma, myocardial infarction, stroke, or documented sepsis. Charts also were examined for the presence of nephrotoxic cofactors (ie, hypovolemia and/or acidosis). RESULTS All 35 patients were men without significant past medical history and were an average age of 24.4 years. The average admission creatine phosphokinase was 40,471 U/L. No patient presented with or developed nephrotoxic cofactors during hospitalization. None of our study patients experienced acute renal failure. CONCLUSION Previous literature has described a 17% to 40% incidence of acute renal failure in rhabdomyolysis. None of our patients developed acute renal failure, signifying a much lower incidence of acute renal failure in exercise-induced rhabdomyolysis without nephrotoxic cofactors than in other forms of rhabdomyolysis.

The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs

OBJECTIVES Early recognition and treatment of hemorrhagic shock after trauma limits multi-organ failure and mortality. Traditional vital signs (VS) although specific are not highly sensitive for hemorrhage detection. Metabolic parameters such as lactate and base deficit (BD) are highly sensitive indicators of blood loss by measuring tissue perfusion. Does adding information from BD and lactate to traditional VS improve the identification of trauma patients with major injuries? METHODS We conducted a retrospective study of a prospectively collected database at a Level I trauma center from January 2003 to September 2005. Patients >13 years, suspected of having significant injury by mechanism, were included. Abnormal VS were defined by heart rate >100 beats/min or systolic blood pressure <90 mmHg. Metabolic parameters from initial arterial blood gas were measured in all patients, abnormal defined by BD >-2.0 mMol/L or lactate >2.2 mMol/L. Our outcome variable, major injury, was defined as any trauma patient who received a blood transfusion, or dropped their hematocrit >10 points in the first 24 h, or had an Injury Severity Score (ISS) >15. RESULTS 1435 patients were enrolled, 242 (17%) had major injuries. Abnormal VS alone had a sensitivity of 40.9% (95% CI, 34.7-47.1%) for identifying major injury patients. When abnormal metabolic parameters were added, major injury detection increased significantly to a sensitivity of 76.4% (95% CI, 71.1-81.8%). CONCLUSIONS The addition of BD and lactate to triage vital signs increases the ability to distinguish major from minor injury.

Prehospital stroke scales in urban environments A systematic review

Objective: To identify and compare the operating characteristics of existing prehospital stroke scales to predict true strokes in the hospital. Methods: We searched MEDLINE, EMBASE, and CINAHL databases for articles that evaluated the performance of prehospital stroke scales. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies–2 tool. We abstracted the operating characteristics of published prehospital stroke scales and compared them statistically and graphically. Results: We retrieved 254 articles from MEDLINE, 66 articles from EMBASE, and 32 articles from CINAHL Plus database. Of these, 8 studies met all our inclusion criteria, and they studied Cincinnati Pre-Hospital Stroke Scale (CPSS), Los Angeles Pre-Hospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Medic Prehospital Assessment for Code Stroke (Med PACS), Ontario Prehospital Stroke Screening Tool (OPSS), Recognition of Stroke in the Emergency Room (ROSIER), and Face Arm Speech Test (FAST). Although the point estimates for LAPSS accuracy were better than CPSS, they had overlapping confidence intervals on the symmetric summary receiver operating characteristic curve. OPSS performed similar to LAPSS whereas MASS, Med PACS, ROSIER, and FAST had less favorable overall operating characteristics. Conclusions: Prehospital stroke scales varied in their accuracy and missed up to 30% of acute strokes in the field. Inconsistencies in performance may be due to sample size disparity, variability in stroke scale training, and divergent provider educational standards. Although LAPSS performed more consistently, visual comparison of graphical analysis revealed that LAPSS and CPSS had similar diagnostic capabilities.

Diagnostic Accuracy of History, Physical Examination, and Bedside Ultrasound for Diagnosis of Extremity Fractures in the Emergency Department: A Systematic Review

OBJECTIVES Understanding history, physical examination, and ultrasonography (US) to diagnose extremity fractures compared with radiography has potential benefits of decreasing radiation exposure, costs, and pain and improving emergency department (ED) resource management and triage time. METHODS The authors performed two electronic searches using PubMed and EMBASE databases for studies published between 1965 to 2012 using a strategy based on the inclusion of any patient presenting with extremity injuries suspicious for fracture who had history and physical examination and a separate search for US performed by an emergency physician (EP) with subsequent radiography. The primary outcome was operating characteristics of ED history, physical examination, and US in diagnosing radiologically proven extremity fractures. The methodologic quality of the studies was assessed using the quality assessment of studies of diagnostic accuracy tool (QUADAS-2). RESULTS Nine studies met the inclusion criteria for history and physical examination, while eight studies met the inclusion criteria for US. There was significant heterogeneity in the studies that prevented data pooling. Data were organized into subgroups based on anatomic fracture locations, but heterogeneity within the subgroups also prevented data pooling. The prevalence of fracture varied among the studies from 22% to 70%. Upper extremity physical examination tests have positive likelihood ratios (LRs) ranging from 1.2 to infinity and negative LRs ranging from 0 to 0.8. US sensitivities varied between 85% and 100%, specificities varied between 73% and 100%, positive LRs varied between 3.2 and 56.1, and negative LRs varied between 0 and 0.2. CONCLUSIONS Compared with radiography, EP US is an accurate diagnostic test to rule in or rule out extremity fractures. The diagnostic accuracy for history and physical examination are inconclusive. Future research is needed to understand the accuracy of ED US when combined with history and physical examination for upper and lower extremity fractures.

What is the utility of the Focused Assessment with Sonography in Trauma (FAST) exam in penetrating torso trauma

STUDY OBJECTIVE A recent Cochrane Review has demonstrated that emergency ultrasonography decreases the amount of computerised tomographic scans in blunt abdominal trauma.13 However, there is no systematic review that has evaluated the utility of the Focused Assessment with Sonography for Trauma(FAST) exam in penetrating torso trauma. We systematically reviewed the medical literature for the utility of the FAST exam to detect free intraperitoneal blood after penetrating torso trauma. METHODS We searched PUBMED and EMBASE databases for randomised controlled trials from 1965 through December 2009 using a search strategy derived from the following PICO formulation of our clinical question: PATIENTS patients (12+ years) sustaining penetrating trauma to the torso. INTERVENTION FAST exam during their initial trauma workup. Comparator: either local wound exploration (LWE),computerised tomography (CT), diagnostic peritoneal lavage (DPL), or laparotomy. OUTCOME intraperitoneal and pericardial free fluid. The methodological quality of the studies was assessed.Qualitative methods were used to summarise the study results. ANALYSIS Sensitivities and specificities were compared using a Forest Plot (95% CI) calculated by Revman 5 (Review Manager Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration,2008) between the FAST exam and definitive diagnostic modalities such as LWE, CT, DPL, or laporotomy. RESULTS We identified eight observational studies (n=565 patients) that met our selection criteria. The prevalence of a positive FAST exam after penetrating trauma was fairly low ranging from 24.2% to 56.3%.The FAST exam for penetrating trauma is a highly specific (94.1–100.0%), but not very sensitive (28.1–100%) diagnostic modality. CONCLUSION From the review of the literature, a positive FAST exam has a high incidence of intraabdominal injury and should prompt an exploratory laparotomy. However, a negative initial FAST exam after penetrating trauma should prompt further diagnostic studies such as LWE, CT, DPL, or laparotomy.

A Consensus Parameter for the Evaluation and Management of Angioedema in the Emergency Department

Despite its relatively common occurrence and life-threatening potential, the management of angioedema in the emergency department (ED) is lacking in terms of a structured approach. It is paramount to distinguish the different etiologies of angioedema from one another and more specifically differentiate histaminergic-mediated angioedema from bradykinin-mediated angioedema, especially in lieu of the more novel treatments that have recently become available for bradykinin-mediated angioedema. With this background in mind, this consensus parameter for the evaluation and management of angioedema attempts to provide a working framework for emergency physicians (EPs) in approaching the patient with angioedema in terms of diagnosis and management in the ED. This consensus parameter was developed from a collaborative effort among a group of EPs and leading allergists with expertise in angioedema. After rigorous debate, review of the literature, and expert opinion, the following consensus guideline document was created. The document has been endorsed by the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM).

Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm

BACKGROUND The use of ultrasound (US) to diagnose an abdominal aortic aneurysm (AAA) has been well studied in the radiology literature, but has yet to be rigorously reviewed in the emergency medicine arena. OBJECTIVES This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. METHODS The authors searched PubMed and EMBASE databases for trials from 1965 through November 2011 using a search strategy derived from the following PICO formulation: Patients-patients (18+ years) suspected of AAA. Intervention-bedside ED US to detect AAA. Comparator-reference standard for diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging (MRI), aortography, official US performed by radiology, ED US reviewed by radiology, exploratory laparotomy, or autopsy results. AAA was defined as ≥ 3 cm dilation of the aorta. Outcome-operating characteristics (sensitivity, specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines. RESULTS The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%). CONCLUSIONS Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients.

Novel Influenza A(H1N1) Virus Among Gravid Admissions

BACKGROUND Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population. METHODS We conducted an observational analysis of 18 gravid patients with H1N1 in 2 academic medical centers. Cases were identified based on direct antigen testing (DAT) of nasopharyngeal swabs followed by real-time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture. Patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathologic information were recorded. Results were then compared with published reports of the H1N1 outbreak and reports of flu pandemics of 1918 and 1957. RESULTS Eighteen pregnant patients were admitted with H1N1 during the study period. All patients were treated with oseltamivir phosphate beginning on the day of admission. Mean (SD) age was 27 (6.6) years (age range, 18-40 years); median length of hospital stay was 4 days. Intensive care unit admission rate was 17% (n = 3). Demographically, 2 patients were health care workers (11%); 15 were black (83%); 2, Hispanic (11%); and 1, white (6%). None reported recent travel. Half of the patients presented with gastrointestinal or abdominal complaints; 13 patients met sepsis criteria (72%). The most common comorbidities were asthma, sickle cell disease, and diabetes. Fourteen patients tested positive for H1N1 on DAT (initial or repeated) (78%); in the other 4 cases, H1N1 was identified by viral culture or rRT-PCR (22%). Seven patients delivered during hospitalization (39%), 6 prematurely and 4 via emergency cesarean delivery. There were 2 fetal deaths (11%). No maternal mortality was recorded. CONCLUSIONS Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death. A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes.

Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis

OBJECTIVES The utility of nasogastric aspiration and lavage in the emergency management of patients with melena or hematochezia without hematemesis is controversial. This evidence-based emergency medicine review evaluates the following question: does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding? METHODS MEDLINE, EMBASE, the Cochrane Library, and other databases were searched. Studies were selected for inclusion in the review if the authors had performed nasogastric aspiration (with or without lavage) in all patients with hematochezia or melena and performed esophagogastroduodenal endoscopy (EGD) in all patients. Studies were excluded if they enrolled patients with history of esophageal varices or included patients with hematemesis or coffee ground emesis (unless the data for patients without hematemesis or coffee ground emesis could be separated out). The outcome was identifying upper GI hemorrhage (active bleeding or high-risk lesions potentially responsible for hemorrhage) and the rate of complications associated with the nasogastric tube insertion. Quality of the included studies was assessed using standard criteria for diagnostic accuracy studies. RESULTS Three retrospective studies met our inclusion and exclusion criteria. The prevalence of an upper GI source for patients with melena or hematochezia without hematemesis was 32% to 74%. According to the included studies, the diagnostic performance of the nasogastric aspiration and lavage for predicting upper GI bleeding is poor. The sensitivity of this test ranged from 42% to 84%, the specificity from 54% to 91%, and negative likelihood ratios from 0.62 to 0.20. Only one study reported the rate complications associated with nasogastric aspiration and lavage (1.6%). CONCLUSIONS Nasogastric aspiration, with or without lavage, has a low sensitivity and poor negative likelihood ratio, which limits its utility in ruling out an upper GI source of bleeding in patients with melena or hematochezia without hematemesis.

The utility of shock index in differentiating major from minor injury.

Objective The importance of early recognition of hemorrhagic shock and its effects on outcome have long been recognized. Traditional vital signs are relatively insensitive as early diagnostic markers of hemorrhage. The shock index (SI); heart rate (HR) divided by systolic blood pressure (SBP), has been suggested as such a marker. We tested the diagnostic utility of the SI in differentiating major from minor injury in trauma patients. Methods Retrospective study of a prospectively collected observational cohort at a level I trauma center. Demographics, injury mechanism, HR, SBP, base deficit and lactate were recorded and Injury Severity Score were calculated. Major injury was defined as either a change in hematocrit greater than 10 or blood transfusion requirement during initial 24 h, or Injury Severity Score greater than15. Results One thousand four hundred and thirty-five trauma patients were enrolled, average age 35.2±16.9 years. Two hundred and forty-two were classified as major injury. The area under the receiver operator characteristic curves for SI [0.63 95% confidence interval (CI) 0.59–0.67] was significantly less than that for base deficit (0.72, 95% CI: 0.69–0.76) or lactate (0.69, 95% CI: 0.65–0.73). The diagnostic performance of SI was slightly better than HR (0.58) but not SBP (0.61). To reach sensitivity of 90%, the SI must be 0.5, well in the range of a normal SBP and HR. Conclusion The SI can be a valuable tool, raising suspicion when it is abnormal even when other parameters are not, but is far too insensitive for use as a screening device to rule out disease. A normal SI should not lower the suspicion of major injury.