Osborn Waves in a Severely Hypothermic Patient

History of present illness: A 46-year-old male was brought in by emergency medical services (EMS) after being found unconscious outside. The patient was known to have a history of alcohol abuse and seizure disorder. No other history was available. The patient’s vital signs included a rectal temperature of 26°C, heart rate of 108, blood pressure of 124/95, respiratory rate of 14, and an oxygen saturation of 99% on a non-rebreather mask. He was unresponsive to verbal or tactile stimuli. The decision was made to intubate the patient and begin active rewarming measures. As part of his diagnostic evaluation, an EKG was obtained. Significant findings: The initial EKG shows marked elevation of the J-point (point where the QRS segment joins the ST segment), otherwise known as an “Osborn Wave” (see black arrows). A subsequent EKG obtained after active rewarming, showed resolution of the Osborn waves. Discussion: John Osborn first described this wave in 1953 following his work with hypothermic dogs.1 This wave is known by multiple names including a “J-wave”.2 An Osborn wave is produced when the J-point is markedly deviated from the baseline. Osborn waves are usually seen in leads II, III, aVF, and V3– V6.3 This wave is most commonly seen in the setting of hypothermia but can be seen in other conditions including acute coronary syndrome, hypercalcemia, post-cardiac arrest, severe myocarditis, Brugada syndrome, early repolarization, toxin ingestion, and Takotsubo cardiomyopathy.2 Osborn waves are produced as a result of differences in the transmural voltage gradient that is associated with heterogeneous expression of the transient outward current between the epicardium and the endocardium.4 This voltage gradient, resulting in epicardial notch and Osborn wave, is correlated with hypothermia.4 Osborn waves can be a predictor of mortality in certain situations including hypothermia and acute coronary syndrome.2,5 Reports have demonstrated an inverse relationship between the amplitude of Osborn waves and core body temperature: the waves increasing in amplitude with lower body temperatures. These waves often return to baseline as the body is rewarmed. There are, however, multiple determinants of Osborn waves and they do not strictly correlate with body temperature.6 Rewarming measures can be divided into passive and active rewarming. Passive rewarming simply refers to simply covering the patient with an insulating material in a favorable atmosphere. Active rewarming can be divided into both active external rewarming and active internal rewarming. Active external rewarming can take several forms including application of heating pads, forced air warming systems, radiant heat, and arteriovenous anastomoses rewarming.7 Active internal rewarming may include warmed intravenous fluids, airway rewarming (warmed humidified air via endotracheal tube), warm fluid lavage (gastric, thoracic, peritoneal, bladder), and extracorporeal blood rewarming. The patient in this case underwent both active external (forced air warming system and arteriovenous anastomoses rewarming) and active internal rewarming (warmed intravenous fluids and airway warming). Topics: Hypothermia, Osborn wave, electrocardiogra

An Elderly Female with Dyspnea and Abdominal Pain

History of Present Illness: A 55-year-old female presented via transfer from a referring hospital with 48 hours of abdominal pain, vomiting and dyspnea. She was found to be in severe distress. Her temperature was 37.5° C (99.5° F), heart rate 130 beats per minute, respiratory rate 47 breaths per minute, blood pressure 80/48, and oxygen saturation of 95% on a non-rebreather mask. She had distended neck veins, diminished breath sounds on the left hemi-thorax, and a distended abdomen. A chest x-ray that had been obtained at the referring hospital was immediately reviewed. The decision was made to intubate the patient. Following intubation, a nasogastric tube was placed with marked improvement in her hemodynamics. An abdomen-pelvis CT was obtained which showed a para-esophageal hernia with the majority of the stomach located in the left hemi-thorax and evidence of a bowel obstruction. Significant findings: Radiography shows a dilated, gas-filled structure that fills nearly the entire left hemi-thorax. Lung markings are visible in the uppermost portion of the left hemi-thorax. There is mediastinal shift to the right. In the visualized portion of the abdomen, dilated loops of bowel are also visualized. This constellation of findings is consistent with a tension gastrothorax. Discussion: Tension gastrothorax is a rare complication of blunt trauma, diaphragmatic hernias, and certain surgical procedures.1,2 Clinically, a tension gastrothorax may mimic that of a tension pneumothorax, making it difficult to diagnose.3,4 Stabilizing treatment includes decompressing the stomach by means of a nasogastric (NG) tube.2 Placement may be difficult due the intra-thoracic position of the stomach leading to kinking of the tube. The attempt to place an NG tube can lead to hyperventilation and air swallowing, which can aggravate gastric distention.4 Failure to decompress the stomach, however, may lead to patient decompensation and cardiac arrest.5 Definitive treatment is surgical repair.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study

Introduction: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs.Methods: We queried the 2013 National Emergency Department Sample  using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule.Results: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging.Conclusion: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study

Introduction: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs.Methods: We queried the 2013 National Emergency Department Sample  using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule.Results: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging.Conclusion: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending

Can Artificial Intelligence Enhance Syncope Management?: A JACC: Advances Multidisciplinary Collaborative Statement : State-of-the-Art Review

Syncope, a form of transient loss of consciousness, remains a complex medical condition for which adverse cardiovascular outcomes, including death, are of major concern but rarely occur. Current risk stratification algorithms have not completely delineated which patients benefit from hospitalization and specific interventions. Patients are often admitted unnecessarily and at high cost. Artificial intelligence (AI) and machine learning may help define the transient loss of consciousness event, diagnose the cause, assess short- and long-term risks, predict recurrence, and determine need for hospitalization and therapeutic intervention; however, several challenges remain, including medicolegal and ethical concerns. This collaborative statement, from a multidisciplinary group of clinicians, investigators, and scientists, focuses on the potential role of AI in syncope management with a goal to inspire creation of AI-derived clinical decision support tools that may improve patient outcomes, streamline diagnostics, and reduce health-care costs

SARS-CoV-2 Seroprevalence and Drug Use in Trauma Patients from Six Sites in the United States

In comparison to the general patient population, trauma patients show higher level detections of bloodborne infectious diseases, such as Hepatitis and Human Immunodeficiency Virus. In comparison to bloodborne pathogens, the prevalence of respiratory infections such as SARS-CoV-2 and how that relates with other variables, such as drug usage and trauma type, is currently unknown in trauma populations. Here, we evaluated SARS-CoV-2 seropositivity and antibody isotype profile in 2,542 trauma patients from six Level-1 trauma centers between April and October of 2020 during the first wave of the COVID-19 pandemic. We found that the seroprevalence in trauma victims 18-44 years old (9.79%, 95% confidence interval/CI: 8.33 11.47) was much higher in comparison to older patients (45-69 years old: 6.03%, 4.59-5.88; 70+ years old: 4.33%, 2.54 – 7.20). Black/African American (9.54%, 7.77 – 11.65) and Hispanic/Latino patients (14.95%, 11.80 – 18.75) also had higher seroprevalence in comparison, respectively, to White (5.72%, 4.62 7.05) and Non-Latino patients (6.55%, 5.57 – 7.69). More than half (55.54%) of those tested for drug toxicology had at least one drug present in their system. Those that tested positive for narcotics or sedatives had a significant negative correlation with seropositivity, while those on anti-depressants trended positive. These findings represent an important consideration for both the patients and first responders that treat trauma patients facing potential risk of respiratory infectious diseases like SARS-CoV-2