Susan Wojcik

Incidental Findings on CT Scans in the Emergency Department.

Objectives. Incidental findings on computed tomography (CT) scans are common. We sought to examine rates of findings and disclosure among discharged patients who received a CT scan in the ED. Methods. Retrospective chart review (Aug-Oct 2009) of 600 patients age 18 and older discharged home from an urban Level 1 trauma center. CT reports were used to identify incidental findings and discharge paperwork was used to determine whether the patient was informed of these findings. Results. There were 682 CT scans among 600 patients: 199 Abdomen & Pelvis, 405 Head, and 78 Thorax. A total of 348 incidental findings were documented in 228/682 (33.4%) of the scans, of which 34 (9.8%) were reported to patients in discharge paperwork. Patients with 1 incidental finding were less likely to receive disclosure than patients with 2 or more (P = .010). Patients age <60 were less likely to have incidental findings (P < .001). There was no significant disclosure or incidental finding difference by gender. Conclusions. While previous research suggests that CT incidental findings are often benign, reporting to patients is recommended but this is rarely happening.

Classification accuracy of serum Apo A-I and S100B for the diagnosis of mild traumatic brain injury and prediction of abnormal initial head computed tomography scan.

The objective of the current study was to determine the classification accuracy of serum S100B and apolipoprotein (apoA-I) for mild traumatic brain injury (mTBI) and abnormal initial head computed tomography (CT) scan, and to identify ethnic, racial, age, and sex variation in classification accuracy. We performed a prospective, multi-centered study of 787 patients with mTBI who presented to the emergency department within 6 h of injury and 467 controls who presented to the outpatient laboratory for routine blood work. Serum was analyzed for S100B and apoA-I. The outcomes were disease status (mTBI or control) and initial head CT scan. At cutoff values defined by 90% of controls, the specificity for mTBI using S100B (0.899 [95% confidence interval (CI): 0.78-0.92]) was similar to that using apoA-I (0.902 [0.87-0.93]), and the sensitivity using S100B (0.252 [0.22-0.28]) was similar to that using apoA-I (0.249 [0.22-0.28]). The area under the receiver operating characteristic curve (AUC) for the combination of S100B and apoA-I (0.738, 95% CI: 0.71, 0.77), however, was significantly higher than the AUC for S100B alone (0.709, 95% CI: 0.68, 0.74, p=0.001) and higher than the AUC for apoA-I alone (0.645, 95% CI: 0.61, 0.68, p<0.0001). The AUC for prediction of abnormal initial head CT scan using S100B was 0.694 (95%CI: 0.62, 0.77) and not significant for apoA-I. At a S100B cutoff of <0.060 μg/L, the sensitivity for abnormal head CT was 98%, and 22.9% of CT scans could have been avoided. There was significant age and race-related variation in the accuracy of S100B for the diagnosis of mTBI. The combined use of serum S100B and apoA-I maximizes classification accuracy for mTBI, but only S100B is needed to classify abnormal head CT scan. Because of significant subgroup variation in classification accuracy, age and race need to be considered when using S100B to classify subjects for mTBI.

Evaluation of emergency medicine discharge instructions in pediatric head injury

Objectives Pediatric head trauma is a common occurrence. There is mounting evidence that even patients with minor head injury require limits on school activities and/or removal from sports and play to help speed recovery and limit morbidity. The objective of this study was to determine whether discharge instructions given to children who had sustained head injuries included information regarding activity restrictions, activity time constraints, and/or specifics of follow-up care. Methods This was a retrospective chart review of patients aged 2 to 18 years evaluated and treated for head injury during a 4-month period at a level I trauma center (volume ∼23,000 pediatric patients per year). Included were those children seen, evaluated, and diagnosed with any of the following: mild head injury, concussion, minor head trauma, or mild traumatic brain injury (mTBI). Subjects were excluded if there was a positive acute head injury computed tomography finding (other than findings of a simple linear skull fracture) or if the subject required admission. Results Among the 204 patients meeting eligibility, 95.1% received instruction to follow up with a physician, 82.8% received anticipatory guidance regarding expected symptoms, 15.2% received specific restriction time from sports, and 21.5% were removed from sports. Of these patients, 113 patients were determined “likely” to have sustained an mTBI. Patients with sports-related mTBI received return-to-sports restrictions (&khgr;2 = 11.225, P < 0.008) and to remove the child from play (&khgr;2 = 9.781, P < 0.004) as discharge instructions significantly more than did patients with motor vehicle accident or other mechanisms of injury. Conclusions Children sustaining head injury were inadequately instructed to restrict athletic activities upon discharge. This is particularly true for patients who sustain an mTBI from non–sports-related activity.

Blood culture results do not affect treatment in complicated cellulitis.

BACKGROUND Cellulitis, a frequently encountered complaint in the Emergency Department, is typically managed with antibiotics. There is some debate as to whether obtaining blood cultures and knowing their results would change the management of cellulitis, although most authors argue that information from blood cultures does not change the empirical management of uncomplicated cellulitis. However, for complicated cellulitis (as defined by the presence of significant comorbidity), there is considerable disagreement and lack of evidence as to the utility of blood cultures. OBJECTIVE Our aim was to determine the role of blood cultures in the management of complicated cellulitis. METHODS This retrospective chart review assessed the utility of obtaining blood cultures in complicated cellulitis (as defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of individuals without medical comorbidity. RESULTS Six hundred and thirty-nine patients were identified, 314 of which were deemed cases and 325 controls. Within the cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95% confidence interval 0.99-3.43). A clinically significant change in management (a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325 controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval 0.434-5.5541). CONCLUSIONS Within this cohort of patients with complicated cellulitis, blood cultures rarely changed management from empirical coverage.

CD34+/CD45-dim stem cell mobilization by hyperbaric oxygen — Changes with oxygen dosage☆

Because hyperbaric oxygen treatment mobilizes bone marrow derived-stem/progenitor cells by a free radical mediated mechanism, we hypothesized that there may be differences in mobilization efficiency based on exposure to different oxygen partial pressures. Blood from twenty consecutive patients was obtained before and after the 1st, 10th and 20th treatment at two clinical centers using protocols involving exposures to oxygen at either 2.0 or 2.5 atmospheres absolute (ATA). Post-treatment values of CD34+, CD45-dim leukocytes were always 2-fold greater than the pre-treatment values for both protocols. Values for those treated at 2.5 ATA were significantly greater than those treated at 2.0 ATA by factors of 1.9 to 3-fold after the 10th and before and after the 20th treatments. Intracellular content of hypoxia inducible factors -1, -2, and -3, thioredoxin-1 and poly-ADP-ribose polymerase assessed in permeabilized CD34+ cells with fluorophore-conjugated antibodies were twice as high in all post- versus pre-treatment samples with no significant differences between 2.0 and 2.5 ATA protocols. We conclude that putative progenitor cell mobilization is higher with 2.5 versus 2.0 ATA treatments, and all newly mobilized cells exhibit higher concentrations of an array of regulatory proteins.

Rates of positive blood, urine, and cerebrospinal fluid cultures in children younger than 60 days during the vaccination era.

Background Fever is a common reason children present to the emergency department. The goal of this study was to determine the rates and the etiology of bacterial infection in children younger than 2 months during the vaccination era. Methods This is a retrospective chart review performed at a tertiary care hospital. Electronic medical records were used to identify patients who had a workup for fever/sepsis in the emergency department. The search was limited to identifying only children younger than 60 days. Results A total of 207 patients satisfied the inclusion/exclusion criteria. In children younger than 28 days, the blood culture–positive rate was 2.7% (range, 0.0%–6.4%), the urine culture–positive rate was 10.7% (range, 3.5%–17.8%), and the cerebrospinal fluid–positive rate (excluding enteroviral infections) was 0% (range, 0.0%–3.9%). In children 29 to 60 days, the blood culture–positive rate was 1.5% (range, 0.0%–3.6%), urine culture–positive rate was 8.5% (range, 3.7%–13.3%), and the cerebrospinal fluid–positive rate (excluding enteroviral infections) was 1.7% (range, 0.0%–5.0%). Urinary tract infections due to Escherichia coli were very common, whereas no cases of Haemophilus influenzae and one case of Streptococcus pneumoniae were detected. Conclusions Urinary tract infections due to E. coli are very common in this age group. The classic pathogens H. influenzae and S. pneumoniae were essentially nonexistent in this study possibly because of herd immunity obtained through current vaccination practices.

Utility of an immunization registry in a pediatric emergency department

Objectives: Determine prevalence of participation and underimmunization rate in a regional immunization registry (IR) among patients presenting to a university pediatric emergency department (PED). Rate of agreement between parental report and documented immunization status was also measured. Methods: A convenience sample of parents of patients younger than 11 years registered in the PED were approached with a short questionnaire. When informed consent was obtained, the Central New York (CNY) IR was accessed via computer to see if the child was in the registry and to ascertain if their immunizations were up-to-date (UTD). Rate of agreement between parental report and immunization status documented in the IR was calculated. Results: 698 (97%) of 720 patients consented to participate. Of these, 235 (34%, 95% CI, 30-37) were enrolled in the IR. Eighty-five (36%, 95% CI, 30-42) enrolled patients were under age 2. Sixty-seven (29%, 95% CI, 23-34) were from private group practices, 146 (62%, 95% CI, 56-68) were from university/community health center clinics and the source of primary care for 22 patients (9%) was unknown. Only 67 (29%, 95% CI, 23-34) parents of children in the IR were aware that they were enrolled. Of IR patients, 225 (96%, 95% CI, 93-98) stated they were UTD, while only 143 (61%, 95% CI, 55-67) were documented to be so. Conclusions: A significant number of patients seen in the PED were in the CNY IR. More than one-half of the parents of enrolled children did not recall that they had previously registered their child. Only 61% of patients were UTD, whereas parents reported that almost all were. In the PED, use of an IR would create an opportunity for intervention in a large number of patients who were not UTD.

Predicting mild traumatic brain injury patients at risk of persistent symptoms in the Emergency Department.

Abstract Objective: To identify factors that can predict which emergency department (ED) patients with mTBI are likely to develop persistent post-concussion symptoms (PPCS). Design: A matched case-control study was conducted at a Level 1 trauma centre between June 2006 and July 2009. Patients diagnosed with mTBI in the ED and diagnosed at a concussion management programme with at least one PPCS (85 cases) were compared to patients diagnosed with mTBI in the ED (340 controls) to determine if factors assessed at the time of ED presentation could predict patients likely to develop persistent symptoms. Results: Multivariable hierarchical logistic regression with variables indicating increased risk for PPCS (prior mTBI, history of depression, history of anxiety, multiple injury, forgetfulness/poor memory, noise sensitivity, or light sensitivity) resulted in a final predictive model including prior mTBI, history of anxiety, forgetfulness/poor memory and light sensitivity. The final model had a specificity of 87.9% and a sensitivity of 69.9%. Conclusions: A strong prediction model to identify those ED patients with mTBI at risk for PPCS was developed and could be easily implemented in the ED; therefore, helping to target those patients who would potentially benefit from close follow-up.

Evaluation of ambulance offload delay at a university hospital emergency department.

BackgroundAmbulance offload delay (AOD) has been recognized by the National Association of EMS Physicians (NAEMSP) as an important quality marker. AOD is the time between arrival of a patient by EMS and the time that the EMS crew has given report and moved the patient off of the EMS stretcher, allowing the EMS crew to begin the process of returning to service. The AOD represents a potential delay in patient care and a delay in the availability of an EMS crew and their ambulance for response to emergencies. This pilot study was designed to assess the AOD at a university hospital utilizing direct observation by trained research assistants.FindingsA convenience sample of 483 patients was observed during a 12-month period. Data were analyzed to determine the AOD overall and for four groups of National Emergency Department Overcrowding Scale (NEDOCS) score ranges. The AOD ranged from 0 min to 157 min with a median of 11 min. When data were grouped by NEDOCS score, there was a statistically significant difference in median AOD between the groups (p < 0.001), indicating the relationship between ED crowding and AOD.ConclusionThe median AOD was considered significant and raised concerns related to patient care and EMS system resource availability. The NEDOCS score had a positive correlation with AOD and should be further investigated as a potential marker for determining diversion status or for destination decision-making by EMS personnel.

Backboard time for patients receiving spinal immobilization by emergency medical services

BackgroundUse of backboards as part of routine trauma care has recently come into question because of the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies, aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma center to determine the total and interval backboard times for patients arriving via emergency medical services (EMS).FindingsPatients were directly observed. Transport time was recorded as an estimate of initiation of backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded. National Emergency Department Overcrowding Study (NEDOCS) score, Emergency Severity Index (ESI) and demographic information were recorded for each patient encounter. Forty-six patients were followed. The mean total backboard time was 54 min (SD ±65). The mean EMS interval was 33 min (SD ±64), and the mean ED interval was 21 min (SD ±15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min, 5 = 32 min).ConclusionPatients had a mean total backboard time of around an hour. The mean EMS interval was greater than the mean ED interval. Further study with a larger sample directed to establishing associated factors and to target possible reduction strategies is warranted.