Factors Influencing Analgesic Use for Skatepark-Related Musculoskeletal Injuries

Objective: This study was designed to determine the proportion of patients with skatepark-related musculoskeletal injuries who were administered analgesics in the emergency department (ED) or at discharge, and to determine if differences in use of pain medication varied by injury type, anatomic location, or patient age. Methods: This is a retrospective review of a cohort of consecutive patients with musculoskeletal injuries presenting to a large urban ED from a local skatepark over a 1-year period (1999- 2000). Patients with non-musculoskeletal injuries were excluded. The outcome measure was analgesic use either in the ED or at discharge. Data included demographics, activity during injury, disposition, injury type (fracture or non-fracture), and injury location (upper or lower body). Analgesic data was abstracted from the medical records. Multivariable logistic regression was used to identify independent predictors of receipt of analgesic medications. Results: 85 injured patients were enrolled. No differences in age, sex, activity, or disposition were found comparing those who received analgesics (n=68) to those who did not (n=17). Overall, analgesia was administered to 80% (95% CI = 70 to 88%) of patients; 67% (95% CI = 56 to 77%) in the ED and 64% (95% CI = 52 to 74%) at discharge. Fractures were more likely to receive analgesia (adjusted OR = 18.5; 95% CI = 4.0 to 86.1) than non-fracture injuries. Lower body injuries were more likely to receive analgesics compared to upper body injuries (adjusted OR = 9.2; 95% CI = 1.5 to 55.8). Age was not independently associated with analgesic use. Conclusions: A high proportion of skatepark-related musculoskeletal injuries were treated with pain medications either in the ED or at discharge. In this study analgesic medication use was influenced by injury type and location of the injury, but not age

A Modified Approach to Supraclavicular Subclavian Vein Catheter Placement: The Pocket Approach

BACKGROUND: Central venous access is often necessary for the administration of fluids, blood products, and medications. Several approaches to supraclavicular subclavian venous access have been described. This study examines the effectiveness of central venous catheter placement utilizing an alternative set of anatomic landmarks for supraclavicular subclavian vein access. METHODS: This was a two phase study. The first portion involved subclavian vein cannulation using a supraclavicular approach in 28 cadavers. The specific set of anatomic landmarks for the supraclavicular approach, termed the “pocket approach,” is described. Cadavers were subsequently dissected to verify appropriate line placement. The second portion was a chart review of Emergency Department (ED) patients who underwent attempted subclavian vein catheter placement utilizing the pocket approach. Charts were extracted following education of the ED faculty and resident staff to determine: 1) Success of subclavian line placement, 2) The incidence of pneumothorax, and 3) The use of supraclavicular subclavian access in the trauma setting, during cardiopulmonary resuscitation (CPR), and in patients who had cervical collars. RESULTS: In 28 cadavers, the success rate of the pocket approach was 100% (34/34; 95% CI 90% to 100%). Chart review of the 68 patients revealed a success rate of 90% (61/68; CI 80% to 96%). No pneumothoraces were recorded (0/68; CI 0% to 5%). The pocket approach was used successfully in 11 patients with cervical collars, (100%, CI 72% to 100%) and in 15 of 16 patients undergoing CPR (94%, CI 70% to 100%). In four fresh cadavers, the average distance from the posterior subclavian vein to the subclavian artery was 0.40cm, and the dome of the pleura was 1.75cm posterior to the vein. CONCLUSION: Our data suggest that the supraclavicular pocket approach to subclavian vein cannulation is a useful and safe method of adult central venous catheterization, with complication and success rates comparable to more common approaches. The anatomic advantage of a great vein that is closer to the skin and farther from the pleural dome makes this an approach worthy of further investigation

Is there an association between seeing incidents of alcohol or drug use in films and young Scottish adults' own alcohol or drug use? A cross sectional study

<p>Background: As the promotion of alcohol and tobacco to young people through direct advertising has become increasingly restricted, there has been greater interest in whether images of certain behaviours in films are associated with uptake of those behaviours in young people. Associations have been reported between exposure to smoking images in films and smoking initiation, and between exposure to film alcohol images and initiation of alcohol consumption, in younger adolescents in the USA and Germany. To date no studies have reported on film images of recreational drug use and young people's own drug use.</p> <p>Methods: Cross sectional multivariable logistic regression analysis of data collected at age 19 (2002-4) from a cohort of young people (502 boys, 500 girls) previously surveyed at ages 11 (in 1994-5), 13 and 15 in schools in the West of Scotland. Outcome measures at age 19 were: exceeding the 'sensible drinking' guidelines ('heavy drinkers') and binge drinking (based on alcohol consumption reported in last week), and ever use of cannabis and of 'hard' drugs. The principle predictor variables were an estimate of exposure to images of alcohol, and of drug use, in films, controlling for factors related to the uptake of substance use in young people.</p> <p>Results: A third of these young adults (33%) were classed as 'heavy drinkers' and half (47%) as 'binge drinkers' on the basis of their previous week's consumption. Over half (56%) reported ever use of cannabis and 13% ever use of one or more of the 'hard' drugs listed. There were linear trends in the percentage of heavy drinkers (p = .018) and binge drinkers (p = 0.012) by film alcohol exposure quartiles, and for ever use of cannabis by film drug exposure (p = .000), and for ever use of 'hard' drugs (p = .033). The odds ratios for heavy drinking (1.56, 95% CI 1.06-2.29 comparing highest with lowest quartile of film alcohol exposure) and binge drinking (1.59, 95% CI 1.10-2.30) were attenuated by adjustment for gender, social class, family background (parental structure, parental care and parental control), attitudes to risk-taking and rule-breaking, and qualifications (OR heavy drinking 1.42, 95% CI 0.95-2.13 and binge drinking 1.49, 95% CI 1.01-2.19), and further so when adjusting for friends' drinking status (when the odds ratios were no longer significant). A similar pattern was seen for ever use of cannabis and 'hard' drugs (unadjusted OR 1.80, 95% CI 1.24-2.62 and 1.57, 95% CI 0.91-2.69 respectively, 'fully' adjusted OR 1.41 (0.90-2.22 and 1.28 (0.66-2.47) respectively).</p> <p>Conclusions: Despite some limitations, which are discussed, these cross-sectional results add to a body of work which suggests that it is important to design good longitudinal studies which can determine whether exposure to images of potentially health-damaging behaviours lead to uptake of these behaviours during adolescence and early adulthood, and to examine factors that might mediate this relationship.</p&gt

Impact of Optimized Breastfeeding on the Costs of Necrotizing Enterocolitis in Extremely Low Birthweight Infants

To estimate risk of NEC for ELBW infants as a function of preterm formula and maternal milk (MM) intake and calculate the impact of suboptimal feeding on NEC incidence and costs

Evidence-based emergency care: diagnostic testing and clinical decision rules

xi+283hlm.;22c

Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Introduction: Prior studies have reported conflicting results regarding the utility of ultrasound in thediagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensiveexperience. This study evaluates the characteristics of ultrasound for PTX for a large cohort oftrauma and emergency physicians.Methods: This was a prospective, observational study on a convenience sample of patientspresenting to a trauma center who had a thoracic ultrasound (TUS) evaluation for PTX performedafter the Focused Assessment with Sonography for Trauma exam. Sonologists recorded theirfindings prior to any other diagnostic studies. The results of TUS were compared to one or more ofthe following: chest computed tomography, escape of air on chest tube insertion, or supine chestradiography followed by clinical observation.Results: There were 549 patients enrolled. The median injury severity score of the patients was 5(inter-quartile range [IQR] 1-14); 36 different sonologists performed TUS. Forty-seven of the 549patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTXfor a sensitivity of 57% (confidence interval [CI] 42-72%). There were 3 false positive cases of TUSfor a specificity of 99% (CI 98%-100%). A “wet” chest radiograph reading done in the trauma bayshowed a sensitivity of 40% (CI 23-59) and a specificity of 100% (99-100).Conclusion: In a large heterogenous group of clinicians who typically care for trauma patients, thesonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracicultrasound may be helpful in the initial evaluation of patients with truncal trauma

Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax

Introduction: Prior studies have reported conflicting results regarding the utility of ultrasound in the diagnosis of traumatic pneumothorax (PTX) because they have used sonologists with extensive experience. This study evaluates the characteristics of ultrasound for PTX for a large cohort of trauma and emergency physicians. Methods: This was a prospective, observational study on a convenience sample of patients presenting to a trauma center who had a thoracic ultrasound (TUS) evaluation for PTX performed after the Focused Assessment with Sonography for Trauma exam. Sonologists recorded their findings prior to any other diagnostic studies. The results of TUS were compared to one or more of the following: chest computed tomography, escape of air on chest tube insertion, or supine chest radiography followed by clinical observation. Results: There were 549 patients enrolled. The median injury severity score of the patients was 5 (inter-quartile range [IQR] 1-14); 36 different sonologists performed TUS. Forty-seven of the 549 patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTX for a sensitivity of 57% (confidence interval [CI] 42-72%). There were 3 false positive cases of TUS for a specificity of 99% (CI 98%-100%). A “wet” chest radiograph reading done in the trauma bay showed a sensitivity of 40% (CI 23-59) and a specificity of 100% (99-100). Conclusion: In a large heterogenous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma. [West J Emerg Med 2013;14(2):103-108.