Visual Diagnosis : Right-Side Diaphragm Injury Resulting from Blunt Trauma
Rory Howard, MD; A. Alijani, MD; Imtiaz A. Munshi, MD, MBA, FACS

Case Report
A 35-year-old man was involved in a snowmobile crash. He was transported by pre-hospital personnel to our Level I Trauma Center. Upon arrival, the primary survey revealed an awake, alert, and oriented individual, who complained of difficulty breathing and right hip pain. The admission vitals were significant for a heart rate of 104 beats/min with a normal blood pressure, respiratory rate, oxygen saturation of 98%, and temperature of 36°C (97°F). On physical examination there were decreased right-sided breath sounds at the base, and he experienced tenderness to palpation over the right chest wall.

Abdominal examination elicited tenderness to palpation at the right upper and lower abdominal quadrants. The pelvis was stable. Radiographic evaluation included a chest X-ray study that revealed decreased right lung aeration and right basilar opacification (Figure 1). Initial interpretation of the chest film suggested a right-sided pneumothorax with pulmonary contusion and a slight right diaphragmatic elevation. A chest tube was inserted into the right pleural space. There was reportedly a rush of air and 40 mL bloody output. Further radiographic evaluation included computed tomography (CT) scans of the chest, abdomen, and pelvis with intravenous and oral contrast (Figure 2). The chest CT scan showed the liver to be intrathoracic, a chest tube over the diaphragm posteriorly, a right diaphragm rupture, compression of the right middle and lower lung lobes, and multiple right-sided rib fractures (Figure 3, Figure 4). The patient was taken urgently to the operating room for an exploratory laparotomy. He was found to have a large central tear in the right diaphragm (14 × 5 cm); the right hepatic lobe was located entirely within the chest and there was a small laceration of the dome of the liver. He had no other abdominal injuries. The liver was manually reduced into the peritoneal cavity, and the diaphragm closed primarily with a running non-absorbable suture. He spent 4 days in the intensive care unit post-operatively. He recovered uneventfully, and was discharged home 10 days after surgery.

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Can Urine Dipstick be Used as a Surrogate for Serum Creatinine in
Emergency Department Patients Who Undergo Contrast Studies?
Daniel Firestone, MD; Adam Wos, MD; James P. Killeen, MD; Theodore C. Chan, MD; Kama Guluma, MD; Daniel P. Davis, MD; Gary M. Vilke, MD

Abstract
Contrast-induced nephropathy (CIN) is a complication associated with contrasted computed tomography (CT). Elevated creatinine (Cr) is often used to screen for CIN. This study evaluates dipstick urinalysis (Udip) detection of Cr > 1.5 mg/dL. If sufficiently sensitive, Udip results could then be incorporated into future rapid screening protocols for patients undergoing contrast studies. This retrospective record review evaluated all Emergency Department patients over 2 years with documented Udip and serum creatinine results. Patient demographics and pertinent past medical history were also collected. Data were collected on 2421 patient visits, with 241 having Cr > 1.5 mg/dL (9.9%).

There were 923 patient visits with a negative Udip (38.1%). Sensitivity and negative predictive value for abnormal Udip in detecting elevated creatinine were 85.5% and 96.2% (p < 0.01), respectively. Thirty-five patient visits (among 26 patients) had negative urine dip and Cr > 1.5 mg/dL, but each reported at least one of the following at triage: prior renal disease, hypertension, diabetes, congestive heart failure, or age > 60 years. Udip is a sensitive screening test, but alone is not accurate enough to predict patients at potential risk for CIN (Cr > 1.5 mg/dL). However, combining Udip results with risk factor screening may allow a rapid method for predicting which patients may safely undergo contrast CT scanning in the ED, but this needs prospective evaluation.

Introduction
Patients who present to the Emergency Department (ED) commonly require intravenous (i.v.) contrast for computed tomography (CT) scans. Contrast-induced nephropathy (CIN) is a potential complication of intravenous contrast administration. In the general population, the incidence of CIN is estimated to be 1 6%. However, the risk may be as high as 50% in somepatient subgroups.[1]

There are more than one million contrast studies performed in the United States each year, with approximately 150,000 cases of CIN occurring annually. Contrast-induced nephropathy is the third most common cause of hospital-acquired renal failure, with about 1% of these hospitalized cases requiring dialysis. The development of CIN increases average length of stay in hospitals by 2 additional days. In the critical care population, in-house mortality rate has been described at 36%, with 19% survival rate at 2 years.[2] In general, most cases of CIN resolve without the need for treatment, but there is a 0.5 2.0% risk of needing dialysis associated with the development of CIN among all patients.

Certain populations seem to be at risk for developing CIN. These include patients with pre-existing renal impairment, diabetes, hypertension, congestive heart failure, advanced age, volume depletion, use of nephrotoxic medications, and large volume or high osmolality of the contrast agent.[3]

Contrast-induced nephropathy risk increases as glomular filtration rate (GFR) decreases in a curvilinear fashion. A breakpoint for increased risk of CIN is found at GFR < 60 mL/min/1.73 m2. This correlates with a serum creatinine of > 1.5 mg/dL. Other surrogates for abnormal GFR include 24-h urine protein collection and spot urine protein-to-creatinine ratio. Both of these have either time or cost limitations for conventional ED applications. For its relative simplicity, the serum creatinine is used at many hospitals to determine whether a patient is a candidate for i.v. contrast administration, with a serum creatinine of 1.5 mg/dL or greater being considered a contraindication to contrast dye due to the presumed increased risk of contrast-induced nephropathy. Radiology protocols often require obtaining a serum creatinine before a contrast study can be performed. This may cause delays in diagnosis and patient throughput times in the ED.

Urine dipstick (Udip) has been used successfully as a screening test for serum creatinine elevation in ED patients with severe hypertension.[4] Specifically, proteinuria and hematuria on dipstick urinalysis correlate with impaired renal function. Karras et al. found that the Udip was 96% sensitive and 87% specific for detection of significant proteinuria.[4] It was 91 100% sensitive and 65 99% specific for detection of microscopic hematuria. Point-of-care proteinuria or hematuria identified 100% of severely hypertensive patients with Cr > 1.2 mg/dL in one ED study.[4]

This study was designed to determine if the urine dipstick can reliably detect an elevation in serum creatinine > 1.5 mg/dL in a whole population of ED patients. Serum creatinine is an imperfect surrogate, only in part due to the delay in acquiring and acting on the laboratory test results in real ED time. Its prevalence in radiology protocols warrants the design of more efficient ways for screening for occult elevated values. This phase one study is intended to be followed by a prospective study that will test a more exhaustive screening protocol for patients at risk for CIN.

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Tension Pneumothorax Managed Without Immediate Needle Decompression
Stewart Siu Wa Chan, MBBS(Syd), FRCSEd, FHKAM (Emergency Medicine)

Abstract
Standard medical reference texts state that the immediate life-saving treatment for tension pneumothorax is needle decompression. This article reports a case of an 85-year-old man with tension pneumothorax who was managed without performing immediate needle decompression. Emergency physicians should be aware of the proper management of such cases.

There seems to be a growing body of evidence in the literature to suggest that in spontaneously breathing patients with tension pneumothorax, the rate of deterioration of this condition is much less rapid compared to ventilated patients, and the risks of performing needle decompression need to be balanced against the benefits of this procedure. In the absence of hemodynamic instability or severe respiratory insufficiency, the proper approach to managing such cases may be to carefully monitor the patient, promptly obtain portable chest radiography, and immediately perform chest tube drainage once the diagnosis is confirmed.

Introduction
Tension pneumothorax is a well-known life-threatening condition and it has long been taught that emergency treatment involves immediate needle decompression. However, the literature has numerous reports of the shortcomings or failure of this modality of treatment.[1-6] There are also at least three case reports describing patients with tension pneumothorax managed successfully by chest tube drainage, without performing immediate needle decompression.[7-9] There seem to be certain clinical situations in which immediate chest tube drainage may be a better option than needle decompression for the management of tension pneumothorax.

Although standard medical textbooks and expert authorities correctly emphasize careful clinical diagnosis and the indications for immediate needle decompression, most fail to mention how to manage a subset of lower-risk cases of pneumothorax in which tension is thought to exist but needle decompression may not be a necessary immediate step.[10-15] Hence, emergency physicians encountering such situations may be faced with a dilemma in the choice of treatment. Leigh-Smith and Harris have addressed this issue in a recent extensive review of literature, and they urge that it is time physicians have a "re-think".[4] The following case report is illustrative of a typical scenario.

Case Report
An 85-year-old man was brought to the Emergency Department by ambulance complaining of shortness of breath. Paramedics detected his oxygen saturation at home on room air to be 79% and he was given oxygen therapy. On arrival, hisheart rate was 127 beats/min, blood pressure 149/75 mm Hg, temperature 38.9°C, respiratory rate 22 breaths/min, and oxygen saturation 94% on 3 L/min oxygen, and he was fully conscious.

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Evaluation and Management of Moderate to Severe Pediatric Head Trauma

Anand Swaminathan, MD, MPH; Phil Levy, MD; Eric Legome, MD

Abstract
A case of pediatric head trauma is presented with a detailed discussion of current concepts in evaluation and treatment. Management of the moderate to severe head-injured child is reviewed, and best practices for emergency department treatment are discussed.

Background: Pediatric head trauma is a common and potentially devastating injury. Thorough knowledge of the clinical evaluation and treatment will assist the emergency physician in providing optimal care.

Discussion: Using a case-based scenario, the initial management strategies along with rationale evidence-based treatments are reviewed.

Conclusions: Computed tomography scan is the diagnostic test of choice for the moderate to severe head-injured pediatric patient. Several unique scales to describe and prognosticate the head injury are discussed, although currently, the Glasgow Coma Scale is still the most commonly accepted one. Similar to the adult patient, avoidance of hypotension and hypoxia are key to decreasing mortality. Etomidate and succinylcholine remain the choice of medications for intubation. Hyperventilation should be avoided.

Case Presentation
A 35-day-old ex-premature 35-week boy was brought in by Emergency Medical Services (EMS) after a witnessed fall out of a baby carrier down 15 carpeted steps. The parents stated that the child continued breathing, but was otherwise unresponsive to voice or pain for 30 s, and then began to cry inconsolably. They denied witnessing vomiting or seizure-like activity after the fall. EMS secured the patient in his baby carrier and transported the child to the Emergency Department (ED). En route, the patient was crying, with episodes of decreased responsiveness. On ED arrival, vital signs revealed a blood pressure of 51/24 mm Hg, a heart rate of 171 beats/min, respiratory rate of 44 breaths/min, and an oxygen saturation of 100% on room air. On primary survey, the airway appeared patent. Breathing was normal and breath sounds were equal bilaterally. The child was pink in color with strong brachial and femoral pulses bilaterally. He opened his eyes to painful stimuli but not spontaneously, and would move all four extremities equally without any specific response to pain. The patient made no vocal response. The initial pediatric Glasgow Coma Scale (GCS) was 6.

Immediately upon arrival, intravenous access was established, the patient was placed on a monitor, and blow-by oxygen was delivered. The patient's neck was also immobilized. Secondary survey revealed a large hematoma over the left frontoparietal region without any evidence of laceration. The anterior fontanelle was open and flat and there were no palpable skull fractures. Pupils were 5 mm bilaterally and reactive to light. The chest, abdomen, and extremity examinations were unremarkable. A bedside FAST (focused assessment with sonography in trauma) examination revealed no evidence of free intra-peritoneal fluid or pericardial effusion

After the secondary survey was completed, the patient had recurrent, intermittent apneic episodes lasting 56 s each. Bag-valve-mask ventilation was initiated and intubation was attempted. Intubation was complicated by emesis and desaturation, but eventually the airway was secured. Because the blood pressure after intubation was 45/23 mm Hg, a 60-cc bolus of normal saline was administered, with a resultant increase in blood pressure to 57/35 mm Hg.

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Emergency Department Procedural Sedation with Propofol: Is it Safe?

Christopher S. Weaver, MD;* William E. Hauter, MD;* Edward J. Brizendine, MS; William H. Cordell, MD

Abstract
Propofol is a sedative agent gaining popularity for Emergency Department Procedural Sedation (EDPS). However, some institutions across the country continue to restrict the use of propofol secondary to safety concerns. The purpose of our study was to evaluate the complication rate of EDPS with propofol. We conducted a prospective, observational, multi-center study of EDPS patients aged 18 years, consenting to procedural sedation with propofol. Eighty-two patients from two Level I trauma centers were enrolled between August 1, 2002 and January 31, 2003. Transient hypoxemia was the only noted sedation complication. Nine patients (11%) had brief hypoxemia.

The combined average hypoxemia time was 1.2 min (SD 0.4), and in all instances responded to simple airway maneuvers or increased oxygen concentration. No patient required advanced airway maneuvers such as intubation or even positive pressure ventilation. EDPS with propofol seems to be safe in our population.

Introduction
In emergency medicine, sedatives or analgesics are frequently administered during brief, painful procedures (e.g., fracture or dislocation reduction, abscess incision and drainage, wound care, etc.). This is termed "emergency department procedural sedation" (EDPS) and various individual sedatives or a combination of sedatives may be utilized.
Propofol is a sedative agent that has recently become popular for EDPS. It has many characteristics that make it attractive for emergency department procedural sedation, including rapid induction of sedation and an extremely short half-life, leaving the patient with no residual sedation soon after the procedure is over.[35] Although the use of propofol during EDPS is increasing, some institutions across the country continue to restrict its usesecondary to safety concerns.

We conducted a prospective study to evaluate the complication rate of propofol during EDPS. In addition, we sought to investigate any possible predictors of those patients who might develop sedation events or complications when sedated with propofol.

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Decreased Glasgow Coma Scale Score Does Not Mandate

Endotracheal Intubation in the Emergency Department
Russell Duncan, MBCHB, MRCS(A&E); Shobhan Thakore, MBCHB, BMSC(HONS), FRCS(A&E) FCEM

Abstract
Background: Decreased consciousness is a common reason for presentation to the emergency department (ED) and admission to acute hospital beds. In trauma, a Glasgow Coma Scale score (GCS) of 8 or less indicates a need for endotracheal intubation. Some advocate a similar approach for other causes of decreased consciousness, however, the loss of airway reflexes and risk of aspiration cannot be reliably predicted using the GCS alone.

Study Objective: A survey of all poisoned patients with a decreased GCS who were admitted to an ED short-stay ward staffed by experienced emergency physicians, to establish the incidence of clinically significant aspiration or other morbidities and endotracheal intubation.

Methods: A prospective, observational study was conducted of all patients admitted to the ED short-stay ward with a decreased level of consciousness (GCS < 15). Results: The study included 73 patients with decreased consciousness as a result of drug or alcohol intoxication. The GCS ranged from 3 to 14, and 12 patients had a GCS of 8 or less. No patient with a GCS of 8 or less aspirated or required intubation. There was one patient who required intubation; this patient had a GCS of 12 on admission to the ward.

Conclusions: This study suggests that it can be safe to observe poisoned patients with decreased consciousness, even if they have a GCS of 8 or less, in the ED.

Introduction
A decreased level of consciousness is a common reason for presentation to the emergency department (ED) and is often the result of intoxication. Originally described in head-injured patients, the Glasgow Coma Scale (GCS) was devised as a tool for recording the level of consciousness at a particular moment, whatever the cause of impairment, systematically and reproducibly.[1] Repeated recordings can give an impression of deterioration or improvement. It has gained acceptance in the management of trauma and poisoned patients presenting to the ED.[25]

Established trauma teachings describe a GCS of 8 or less as necessitating endotracheal intubation in recognition of the high risk of secondary brain injury resulting from hypoxemia and hypercapnia caused by airway obstruction or respiratory compromise.[2,3]

It has also been said that a GCS of 8 or less is a useful guide for the requirement of endotracheal intubation where the cause of coma is poisoning.[5,6] Poisoned patients are unlikely to suffer from secondary brain injury, but decreased consciousness and loss of protective airway reflexes predispose to respiratory failure and aspiration injury.[6] However, the risk of aspiration is not confined to patients with a GCS of 8 or less, and the loss of airway reflexes cannot be reliably predicted using the GCS alone.[711]

Respiratory failure and aspiration can be prevented by endotracheal intubation and mechanical ventilation, however, intensive care beds are a limited and expensive resource and must be used judiciously. This observational study aimed to examine the profile of poisoned patients admitted to the ED short-stay ward with a decreased GCS, including their diagnoses, length of stay, and occurrence of significant events. The aim was to establish the incidence of clinically significant aspiration or other morbidities, and endotracheal intubation.

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