Man With Bilateral Leg Swelling

A 52-year-old man without known medical history presented with painful, progressive, bilateral lower extremity edema over a two-week period. An abdominal exam noted a firm left upper quadrant mass. Emergency department (ED) point-of-care ultrasound (POCUS) revealed a hyperechoic, heterogeneous structure in the inferior vena cava that was determined to represent a tumor thrombus extending from a primary renal cell carcinoma. This case demonstrates how POCUS was valuable in rapidly diagnosing this rare cause of lower extremity edema and its usefulness in directing the initial ED management of this patient

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock.Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma.Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma  (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0).Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock

Man With Bilateral Leg Swelling

A 52-year-old man without known medical history presented with painful, progressive, bilateral lower extremity edema over a two-week period. An abdominal exam noted a firm left upper quadrant mass. Emergency department (ED) point-of-care ultrasound (POCUS) revealed a hyperechoic, heterogeneous structure in the inferior vena cava that was determined to represent a tumor thrombus extending from a primary renal cell carcinoma. This case demonstrates how POCUS was valuable in rapidly diagnosing this rare cause of lower extremity edema and its usefulness in directing the initial ED management of this patient

Artificial intelligence to support out-of-hospital cardiac arrest care: A scoping review.

BACKGROUND: Artificial intelligence (AI) has demonstrated significant potential in supporting emergency medical services personnel during out-of-hospital cardiac arrest (OHCA) care; however, the extent of research evaluating this topic is unknown. This scoping review examines the breadth of literature on the application of AI in early OHCA care. METHODS: We conducted a search of PubMed®, Embase, and Web of Science in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. Articles focused on non-traumatic OHCA and published prior to January 18th, 2023 were included. Studies were excluded if they did not use an AI intervention (including machine learning, deep learning, or natural language processing), or did not utilize data from the prehospital phase of care. RESULTS: Of 173 unique articles identified, 54 (31%) were included after screening. Of these studies, 15 (28%) were from the year 2022 and with an increasing trend annually starting in 2019. The majority were carried out by multinational collaborations (20/54, 38%) with additional studies from the United States (10/54, 19%), Korea (5/54, 10%), and Spain (3/54, 6%). Studies were classified into three major categories including ECG waveform classification and outcome prediction (24/54, 44%), early dispatch-level detection and outcome prediction (7/54, 13%), return of spontaneous circulation and survival outcome prediction (15/54, 20%), and other (9/54, 16%). All but one study had a retrospective design. CONCLUSIONS: A small but growing body of literature exists describing the use of AI to augment early OHCA care

Chagas Disease-induced Sudden Cardiac Arrest

Sudden cardiac death (SCD) is the most common cause of death in patients with Chagas disease (ChD). There are over 300,000 ChD-infected individuals living in the United States, of whom 10-15% have undiagnosed Chagas cardiomyopathy (CCM). CCM patients have a higher risk of SCD compared to non-CCM patients, although early and appropriate treatment of CCM patients can result in a 95% relative risk reduction of SCD. Emergency physicians have a unique opportunity to improve outcomes among these patients by becoming more vigilant in recognizing the signs and symptoms of CCM in patients who present in sudden cardiac arrest. We report the case of a patient presenting to the emergency department with pulseless ventricular tachycardia and an undiagnosed history of CCM

Accuracy of Perceived Estimated Travel Time by EMS to a Trauma Center in San Bernardino County, California

Introduction: Mobilization of trauma resources has the potential to cause ripple effects throughout hospital operations. One major factor affecting efficient utilization of trauma resources is a discrepancy between the prehospital estimated time of arrival (ETA) as communicated by emergency medical services (EMS) personnel and their actual time of arrival (TOA). The current study aimed to assess the accuracy of the perceived prehospital estimated arrival time by EMS personnel in comparison to their actual arrival time at a Level II trauma center in San Bernardino County, California.Methods: This retrospective study included traumas classified as alerts or activations that were transported to Arrowhead Regional Medical Center in 2013. We obtained estimated arrival time and actual arrival time for each transport from the Surgery Department Trauma Registry. The difference between the median of ETA and actual TOA by EMS crews to the trauma center was calculated for these transports. Additional variables assessed included time of day and month during which the transport took place.Results: A total of 2,454 patients classified as traumas were identified in the Surgery Department Trauma Registry. After exclusion of trauma consults, walk-ins, handoffs between agencies, downgraded traumas, traumas missing information, and traumas transported by agencies other than American Medical Response, Ontario Fire, Rialto Fire or San Bernardino County Fire, we included a final sample size of 555 alert and activation classified traumas in the final analysis. When combining all transports by the included EMS agencies, the median of the ETA was 10 minutes and the median of the actual TOA was 22 minutes (median of difference=9 minutes, p<0.0001). Furthermore, when comparing the difference between trauma alerts and activations, trauma activations demonstrated an equal or larger difference in the median of the estimated and actual time of arrival (p<0.0001). We also found month and time of day to be associated with variability in the difference between the median of the estimated andactual arrival time (p=0.0082 and p=0.0005 for month and time of the day, respectively).Conclusion: EMS personnel underestimate their travel time by a median of nine minutes, which may cause the trauma team to abandon other important activities in order to respond to the emergency department prematurely. The discrepancy between ETA and TOA is unpredictable, varying by month and time of day. As such, a better method of estimating patient arrival time is needed

Ozz-E3, A Muscle-Specific Ubiquitin Ligase, Regulates β-Catenin Degradation during Myogenesis

AbstractThe identities of the ubiquitin-ligases active during myogenesis are largely unknown. Here we describe a RING-type E3 ligase complex specified by the adaptor protein, Ozz, a novel SOCS protein that is developmentally regulated and expressed exclusively in striated muscle. In mice, the absence of Ozz results in overt maturation defects of the sarcomeric apparatus. We identified β-catenin as one of the target substrates of the Ozz-E3 in vivo. In the differentiating myofibers, Ozz-E3 regulates the levels of sarcolemma-associated β-catenin by mediating its degradation via the proteasome. Expression of β-catenin mutants that reduce the binding of Ozz to endogenous β-catenin leads to Mb-β-catenin accumulation and myofibrillogenesis defects similar to those observed in Ozz null myocytes. These findings reveal a novel mechanism of regulation of Mb-β-catenin and the role of this pool of the protein in myofibrillogenesis, and implicate the Ozz-E3 ligase in the process of myofiber differentiation

Evaluation of the effect of methamphetamine on traumatic injury complications and outcomes

Abstract Background This study investigates the impact of methamphetamine use on trauma patient outcomes. Methods This retrospective study analyzed patients between 18 and 55 years old presenting to a single trauma center in San Bernardino County, CA who sustained traumatic injury during the 10-year study period (January 1st, 2005 to December 31st, 2015). Routine serum ethanol levels and urine drug screens (UDS) were completed on all trauma patients. Exclusion criteria included patients with an elevated serum ethanol level (> 0 mg/dL). Those who screened positive on UDS for only methamphetamine and negative for cocaine and cannabis (MA(+)) were compared to those with a triple negative UDS for methamphetamine, cocaine, and cannabis (MA(−)). The primary outcome studied was the impact of a methamphetamine positive drug screen on hospital mortality. Secondary outcomes included length of stay (LOS), heart rate, systolic and diastolic blood pressure (SBP and DBP, respectively), and total amount of blood products utilized during hospitalization. To analyze the effect of methamphetamine, age, gender, injury severity score, and mechanism of injury (blunt vs. penetrating) were matched between MA(−) and MA(+) through a propensity matching algorithm. Results After exclusion, 2538 patients were included in the final analysis; 449 were patients in the MA(+) group and 2089 patients in the MA(−) group. A selection of 449 MA(−) patients were matched with the MA(+) group based on age, gender, injury severity score, and mechanism of injury. This led to a final sample size of 898 patients with 449 patients in each group. No statistically significant change was observed in hospital mortality. Notably, a methamphetamine positive drug screen was associated with a longer LOS (median of 4 vs. 3 days in MA(+) and MA(−), respectively, p < 0.0001), an increased heart rate at the scene (103 vs. 94 bpm for MA(+) and MA(−), respectively, p = 0.0016), and an increased heart rate upon arrival to the trauma center (100 vs. 94 bpm for MA(+) and MA(−), respectively, p < 0.0001). Moreover, the MA(+) group had decreased SBP at the scene compared to the MA(−) group (127 vs. 132 bpm for MA(+) and MA(−), respectively, p = 0.0149), but SBP was no longer statistically different when patients arrived at the trauma center (p = 0.3823). There was no significant difference in DBP or in blood products used. Conclusion Methamphetamine positive drug screens in trauma patients were not associated with an increase in hospital mortality; however, a methamphetamine positive drug screen was associated with a longer LOS and an increased heart rate

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department

Introduction: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in grossmorbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis(LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. Thisstudy analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed tohave cellulitis, as well as the capability to differentiate cellulitis from NF.Methods: This was a 10-year retrospective chart-review study that included emergency department (ED)patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from0-13 for each patient with all pertinent laboratory values. Three categories were developed per the originalLRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINECscore 6-7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence ofa C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC scorewas 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the“low risk” group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the“high risk” group. These patients missing CRP values were added to these respective groups.Results: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) weremoderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patientswithout CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, atotal of 47 patients were further classified based on LRINEC score without a CRP value. More than half of theNF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to performbetter in the diabetes population than in the non-diabetes population.Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiationbetween cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive ratewhen determining NF risk stratification in confirmed cases of celulitis and a high false negative rate in casesof confirmed NF

Evaluating the Laboratory Risk Indicator to Differentiate Cellulitis from Necrotizing Fasciitis in the Emergency Department

Introduction: Necrotizing fasciitis (NF) is an uncommon but rapidly progressive infection that results in gross morbidity and mortality if not treated in its early stages. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score is used to distinguish NF from other soft tissue infections such as cellulitis or abscess. This study analyzed the ability of the LRINEC score to accurately rule out NF in patients who were confirmed to have cellulitis, as well as the capability to differentiate cellulitis from NF. Methods: This was a 10-year retrospective chart-review study that included emergency department (ED) patients ≥18 years old with a diagnosis of cellulitis or NF. We calculated a LRINEC score ranging from 0–13 for each patient with all pertinent laboratory values. Three categories were developed per the original LRINEC score guidelines denoting NF risk stratification: high risk (LRINEC score ≥8), moderate risk (LRINEC score 6–7), and low risk (LRINEC score ≤5). All cases missing laboratory values were due to the absence of a C-reactive protein (CRP) value. Since the score for a negative or positive CRP value for the LRINEC score was 0 or 4 respectively, a LRINEC score of 0 or 1 without a CRP value would have placed the patient in the “low risk” group and a LRINEC score of 8 or greater without CRP value would have placed the patient in the “high risk” group. These patients missing CRP values were added to these respective groups. Results: Among the 948 ED patients with cellulitis, more than one-tenth (10.7%, n=102 of 948) were moderate or high risk for NF based on LRINEC score. Of the 135 ED patients with a diagnosis of NF, 22 patients had valid CRP laboratory values and LRINEC scores were calculated. Among the other 113 patients without CRP values, six patients had a LRINEC score ≥ 8, and 19 patients had a LRINEC score ≤ 1. Thus, a total of 47 patients were further classified based on LRINEC score without a CRP value. More than half of the NF group (63.8%, n=30 of 47) had a low risk based on LRINEC ≤5. Moreover, LRINEC appeared to perform better in the diabetes population than in the non-diabetes population. Conclusion: The LRINEC score may not be an accurate tool for NF risk stratification and differentiation between cellulitis and NF in the ED setting. This decision instrument demonstrated a high false positive rate when determining NF risk stratification in confirmed cases of cellulitis and a high false negative rate in cases of confirmed NF