The western journal of emergency medicine
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The focused assessment with sonography for trauma (FAST) exam is a routine diagnostic adjunct in the initial assessment of blunt trauma victims but lacks the ability to reliably predict which patients require laparotomy. Physiologic data play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation. The need for laparotomy often influences the decision to transfer the patient to a trauma center. We set out to derive a simple scoring system using both ultrasound findings and immediately available physiologic data that would predict which patients require laparotomy. ⋯ The combination of FAST findings with vital signs in our scoring system predicted which victims of blunt trauma did not undergo laparotomy. Applying this to trauma patients who present to non-trauma centers could help prevent unnecessary patient transfers. This derivation set must be validated prior to use in patient care.
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To determine if a sensitive D-dimer assay can exclude progression to organ dysfunction, death, and intensive care unit (ICU) admission in patients presenting to the emergency department (ED) with suspected infection, and if increasing levels of D-dimer are predictive of those end points. ⋯ This study was limited by its nonconsecutive patient recruitment and sample size. A normal D-dimer may exclude progression to organ dysfunction, ICU admission, and death and, at higher cutoff levels, could help risk stratify patients presenting to the ED with signs of sepsis.
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Despite its widespread use in North America and many other parts of the world, the safety of etomidate as an induction agent for rapid sequence intubation in septic patients is still debated. In this article, we evaluate the current literature on etomidate, review its clinical history, and discuss the controversy regarding its use, especially in sepsis. ⋯ However, because we see a need to balance theoretical harms and benefits in the presence of data supporting the non-inferiority of alternative agents without similar theoretical risks associated with them, we suggest that the burden of proof to support continued widespread use may rest with the proponents of etomidate. We further suggest that practitioners become familiar with the use of more than one agent while awaiting further definitive data.
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Intussusception is a condition found primarily in the pediatric population. In the adult population, however, intussusception is usually due to a pathological process, with a higher risk of bowel obstruction, vascular compromise, inflammatory changes, ischemia, and necrosis. Radiographic and sonographic evidence can aid in the diagnosis. Surgical intervention involving resection of affected bowel is the standard of care in adult cases of intussusception. ⋯ In the adult population, intussusception is usually caused by a lead point, with subsequent telescoping of one part of the bowel into an adjacent segment. While intussusception can occur in any part of the bowel, it usually occurs between a freely moving segment and either a retroperitoneal or an adhesion-fixed segment. The etiology may be associated with pathological processes such as carcinoma or iatrogenic causes, such as scars or adhesions from prior surgeries. The cases presented here demonstrate important etiologies of abdominal pain in adult patients. Along with gynecological etiologies of lower quadrant abdominal pain in female patients, it is important for the emergency physician to expand the differential diagnosis to include other causes, such as intussusceptions, especially given the symptoms that could be associated with bowel obstruction.
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Laryngeal mask airways (LMAs) are often used as airway rescue devices where laryngoscopy is difficult. The LMA does not protect the airway and is preferably replaced with a cuffed endotracheal tube. There are reports of cases where an Eschmann tracheal tube introducer (ETTI) was successfully used to bridge between a standard LMA and an endotracheal tube. This project was designed to determine whether an Eschmann stylet can reliably be passed through an LMA into the trachea as a means of rescue intubation. ⋯ While not a primary difficult airway option, the use of a ETTI as a bridge device between LMA and endotracheal tube was successful about 50% of the time.