Journal of Emergency Medicine, Trauma and Acute Care - Volume 2016, Issue 3

Objective: To correlate collapsibility of the inferior vena cava (IVC) with packed cell volume (PCV) and clinical condition and to ascertain IVC collapsibility as a guide to estimate intravascular volume using bedside ultrasonography (USG) in children with dengue fever. Methods: A prospective observational study was conducted in the Pediatric Emergency Department of an academic hospital in India. Clinical data and PCV of children with dengue fever aged between 1 month to 18 years were documented. The collapsibility of IVC was determined using bedside ultrasonogram. Results: IVC collapsibility correlates with high PCV and dengue shock in children (p = 0.000). IVC was not collapsible in children with normal PCV (p = 0.000). The collapsibility of IVC correlated with the need for normal saline bolus (p = 0.000), colloids (p = 0.002), PICU admission (p = 0.015) and mortality (p = < 0.05). Conclusions: The assessment of intravascular volume status by determining IVC collapsibility using bedside USG is a helpful non-invasive tool in children with dengue fever.

Diabetic muscle infarction (DMI) occurs as a rare complication associated with long-standing, poorly controlled diabetes mellitus (DM) and typically presents as acute painful muscle swelling in the absence of trauma. It resolves spontaneously over a few weeks to months in most patients and generally has a good prognosis. However, the coexistence of deep vein thrombosis (DVT) with DMI may have an additional risk of complications such as pulmonary embolism, recurrent DVT, and post-thrombotic syndrome (PTS). Although the treatment for DMI is mainly analgesia, rest, and control of diabetes, the coexistence of extensive DVT and diabetic ketoacidosis (DKA) may demand anticoagulation and a multidisciplinary team approach. Its management may also involve the endocrinologist, hematologist, and occasionally an interventional radiologist or vascular surgeon. We report two cases of patients with DMI with extensive DVT that presented to our emergency department (ED) as acute non-traumatic swelling of the lower limb. The diagnosis of DMI in both the cases was based on the presence of characteristic clinical features and typical magnetic resonance imaging (MRI) findings. The patients were treated with anticoagulation therapy in addition to the management of DKA, and discharged with good recovery.

Purpose: Hyoid bone fractures are uncommon, reported mainly in cases of hanging. There is a paucity of reports involving other mechanisms, and only a handful of case reports are available to guide the management of these fractures, especially within the emergency department setting. This study focused on identifying optimal initial airway management and subsequent treatment of patients with hyoid fractures. Methods: Patients presenting to an adult major trauma referral centre between January 2007 and July 2014 with a diagnosis of hyoid bone fracture were identified. Patient records were reviewed retrospectively. Results: Of the 19 patients identified, 16 cases were secondary to blunt force trauma. Motor vehicle crashes accounted for eight of the 19 cases. All patients with major trauma were intubated as part of their initial airway management, while 50% of the minor trauma patients were intubated. Only one patient underwent surgical repair of the hyoid bone. Most patients experienced excellent outcomes with no hyoid fracture-related complications. Conclusion: Early intubation for suspected hyoid fractures is advised for those with a penetrating mechanism of injury, clinical features of airway compromise, and severe associated injuries. Conservative, nonsurgical management of hyoid fractures remains the mainstay of management. A minimum 24-hour period of observation for patients who are not managed with endotracheal intubation is advised.

Background: Point-of-care ultrasound (POCUS) is an invaluable tool in the diagnosis and management of conditions presenting to emergency departments across the world. It has also improved the success rate of invasive bedside procedures. Objectives: This study aimed to investigate the current utilization of POCUS in a large tertiary care emergency department in the Middle East and to identify barriers to its utilization. Methods: A cross-sectional survey of emergency physicians' experience with ultrasound was conducted, which included examining the training, exposure, and barriers to use. This paper-based survey was completed by the participants in the presence of the authors of this study to improve compliance. Data were collected over a period of two months, from October to November 2014. Results: A total of 105 physicians participated in the survey. Of these participants, 56 had undergone prior training in ultrasonography by successfully completing courses approved by the Royal College of Emergency Medicine in the United Kingdom, and the Royal College of Physicians and Surgeons of Canada. Twenty-two physicians had completed other non-accredited ultrasound courses. An improvement in ultrasound procedural skills was reported by all those who completed training. A perceived lack of time in the emergency department was the main barrier to scanning patients. Other shortcomings included a deficiency of trained personnel for guidance, shortage of equipment, and a lack of experience and interest among physicians. Hands-on training was considered the preferred method among physicians for enhancing ultrasonography skills. Conclusions: The study identified an underutilization of POCUS by emergency physicians. Availability of dedicated time, equipment, supervision, and training may help to increase its usage.

Introduction: Migraines are one of the commonest presenting complaints to emergency departments (ED), and may result in prolonged length of stay with symptoms being severe and refractory to typical remedies, such as paracetamol, non-steroidal anti-inflammatory drugs and triptans. The objective of this study was to describe and compare patient demographics, presentation, management and outcomes to hospital discharge between first presenters and patients with a history of migraines in two metropolitan emergency departments in Melbourne, Australia. Given that the assessment and management of patients who have had a prior history of migraines is likely to be substantially different, patients were subgrouped by this exposure variable. Methods: A total of 365 patients were identified retrospectively during the study period of March 2013 – September 2014 that met the inclusion criteria of a headache with no organic cause and/or symptoms consistent with visual or abdominal migraines. Presenting pain scores, assessment, management and disposition were extracted using explicit chart review. Results: The mean age of patients included was 37.8 years and 23.3% were males. Significantly more first presenters were investigated with a CT scan of the brain (34.4% as compared to 22.9% of patients with a prior history of migraine).

Initial management included administration of paracetamol in 178 (48.8%) cases, NSAIDs (mostly ibuprofen and aspirin) in 187 (51.2%) and parenteral dopamine antagonists (e.g. metoclopramide, prochlorperazine and chlorpromazine) in 191 (52.3%) cases. Migraine-specific agents such as triptans were prescribed in 46 (12.6%) and ergots in two (0.5%) cases. Opioids such as morphine or oxycodone were administered in 94 (25.8%) cases. There was no statistical difference in the management of patients with a history of migraines as compared to first presenters, with the exception of the use of intravenous fluids and parenteral dopamine antagonists. The median length of stay in the ED was 4 (inter-quartile range 2–7) hours, with 163 (44.7%) patients admitted to the short-stay unit. A pain score of ≥ 5 was recorded at discharge in 31 (8.5%) patients. Disposition was similar across both groups of patients. Conclusions: Although first presenters seem to be more thoroughly investigated, the acute management of migraine did not differ largely between patients who had a history of migraine compared with first presenters. The management of acute migraine in the ED setting has varied efficacy, suggesting that further research into newer therapeutic options is needed.

Biphalangeal toe is a normal anatomic variant where distal and middle phalanges fuse to each other. In the context of trauma, biphalangeal toes may pose a diagnostic challenge and fractures may be interpreted as normal which can lead to misdiagnosis and under treatment. Here, we present a rare case of fracture through a biphalangeal fifth toe with delayed diagnosis. This variation should be kept in mind during the evaluation of a patient with foot trauma and assessment of foot radiographs, particularly in the emergency department where the majority of initial cases are presented.

Many educational tools are used for prehospital trauma life support (PHTLS) training, including mobile apps. This study describes the currently available mobile apps for PHTLS training. Systematic searches in the Apple Store, Google Play Store, and BlackBerry World were conducted in December 2015. Two researchers performed all searches independently and collected their findings in different databases, which were later compared. Finally, a descriptive analysis was carried out. A total of 41 mobile apps that fulfilled the inclusion criteria were found. Among these, 97.5% (n = 40) were in English, 58.5% (n = 24) were updated in 2015, and 51.2% (n = 21) were not free. Of the 20 free apps, 85% (n = 17) did not require an internet connection for any function, 70% (n = 14) had no videos or animation, 10% (n = 2) had any game, and 70% (n = 14) had no institutional certification. In conclusion, it was found that PHTLS apps usually lack interactive content and institutional certification, which should be taken into consideration by users and researchers.

A seven-day-old male neonate presented with symptomatic hypocalcemia in the form of generalized seizure activity for three minutes. He arrived at the pediatric emergency department in a postictal state. His clinical examination was unremarkable, but his initial laboratory evaluation revealed marked hypocalcemia and hypomagnesemia. The patient received intravenous boluses of calcium gluconate for correction. The patient had bradycardia during the first calcium gluconate infusion, and on the second infusion, he developed frequent premature ventricular contractions, which progressed into polymorphic ventricular tachycardia. Arrhythmia reverted to sinus rhythm after discontinuation of the calcium gluconate infusion without the need for chemical/electrical cardioversion. Subsequently, two extra doses of intravenous calcium gluconate for persistent hypocalcemia were administered safely. The patient was discharged home successfully in a good general condition after stabilization. The emergence of bradycardia during calcium gluconate infusion should be considered a red flag since it can trigger serious cardiac arrhythmia, especially in the presence of electrolyte abnormalities such as hypocalcemia and hypomagnesemia. We report this case to stress the need for continuous cardiac monitoring of children on calcium gluconate infusion even if proper dose, dilution, and rate of infusion are used, as serious cardiac arrhythmia can be unpredictable and may develop at any time.

Background: As the cost of attendance for US medical schools continues to increase faster than inflation, students can turn to alternative sources of funding beyond traditional educational loans. The Armed Forces Health Professions Scholarship Program (HPSP) pays for medical students' tuition and fees as well as provides a stipend in exchange for an active-duty service commitment. The aim of this study was to compare the financial impact of an emergency physician joining the military versus taking student loans and going the civilian route. Methods: Cash outflows (in the way of annual attendance costs) and cash inflows (in the form of salaries) were discounted using current student loan interest rates and then added together to calculate the net present values (NPVs) of HPSP versus the civilian route. The numbers for all assumptions were taken from the Association of American Medical Colleges, military pay tables, and physician salary surveys. Results: The NPV of the HPSP for a physician with dependents after four years of practice was found to be $576,432, which is slightly higher than the NPV of civilian physicians, calculated to be $573,351 using a nationwide median annual salary of $300,000. Conclusion: HPSP confers an NPV that is $3080 more than when students take the civilian route. However, any alterations in assumptions regarding pay grade, martial status, or years of service will cause great differences in final calculations. Furthermore, the financial impact of taking the scholarship is only one part of the larger decision-making process when considering to join the military.