A Cause Analysis of Missed Fractures in an Emergency Medical Center

PURPOSE: A missed fracture is a very common occurrence in the Emergency Department (ED) and can have serious results because of delays in treatment, resulting in long-term disability. It is also one of the most common causes leading to medical legal issues. We analyzed the causes of missed fractures by using a bone scan which is known to be an effective tool for diagnosing bony lesions. METHODS: We reviewed the medical records of trauma patients who underwent a bone scan after being discharged the ED from September 2006 to March 2008. Cases of missed fractures were identified by using electronic medical records to review each diagnosis. Definition of missed fracture was read after bone scan by radiologist. We decided that there was no fracture if we read 'trauma-related lesion' or 'cannot rule out fracture' on a bone scan read by a radiologist. Enrolled patients were analyzed by age, sex, time until bone scan and Injury Severity Score (ISS). Patients were divided into two groups, alert mentality and not-alert mentality, so there were split between a diagnosis group and a missed fracture group. ISS was also used in determining the severity of the patient's injury upon discharge from the ED. RESULTS: A total of 532 patients were enrolled in this study. Of those, 487 patients were in the diagnosis group, and 45 patients (8.4%) were discovered to have had a fracture. Of the 45 missed fracture patients, 34 patients (6.4%) had one-site fractures, 8 patients (1.5%) had two-site fractures, and 3 patients (0.6%) had threesite fractures. The most commonly missed fracture was multiple rib fractures (18 patients, 30.5%), followed by lumbosacral (LS) spine fractures (10 patients, 16.9%), thoracic spine fractures (8 patients, 13.6%), and clavicle fractures (6 patients, 10.2%). Mean age was 50.12+/-18.54 years in the diagnosis group and 57.38+/-16.88 years in the missed fracture group. For the diagnosis group, the mean ISS was 9.03+/-8.26, but in the missed fracture group it was 17.53+/-9.69. Missed fractures were much more frequent in the not-alert mentality (p or =16) group (p<0.01). CONCLUSION: Missed fractures occur most frequent in patients of old age, not-alert mentality, and high ISS. Multiple rib and spine fractures were found to be the most frequent missed fractures, regardless of trauma severity. This study also shows a high possibility of clavicle and scapula fractures in patients with severe trauma.

An Emergency Ultrasound (EUS)-Enhanced Scoring System for Diagnosing Acute Appendicitis in Patients with Right Lower Quadrant (RLQ) Pain; Constant or Aggravated Pain, Male Sex, and Ultrasound (CAMUS) Scores

PURPOSE: We hypothesized that a new scoring system that included emergency ultrasound (EUS) and clinical or laboratory predictors for diagnosing acute appendicitis (AA) in patients with right lower quadrant (RLQ) pain could decrease the false negative rate when EUS is performed alone. METHODS: During a 10 month period, patients with RLQ pain were evaluated with EUS just after history taking and physical examination. We also checked the 17 well-known predictors of AA. Univariate analyses for each predictor including EUS findings identified 11 predictors. We then tested those predictors with logistic regression analysis. RESULTS: A total 397 patients (mean age=31.13+/-18.25 years: 196 males, 201 females) were enrolled in this study. Among the 397, 247 underwent an operation, but 14 turned out to have normal appendices. Among 233 patients with appendicitis, 75 had a perforated appendix. Four independent correlates of AA (constant pain, aggravated pain, male sex, and positive EUS findings) were identified with logistic regression analysis. We developed a novel scoring system using regression coefficients as follows: 6 points for a positive EUS, 3 points for aggravated pain, 2 points for constant pain, and 2 points for being male. We named the new scoring system "CAMUS" for "Constant or Aggravated pain, Male sex, and UltraSound score". The area under the receiver-operating characteristic curve (ROC) for the CAMUS score for AA was 0.93(95% confidence interval: 0.871 to 0.959). CONCLUSION: Our new CAMUS scoring system can help emergency physicians diagnose AA accurately and rapidly.

Differential Diagnosis of Acute Dyspnea: The Usefulness of Tissue Doppler Echocardiography in Emergency Department by Emergnecy Physician

PURPOSE: In managing acutely dyspneic patients, differentiating the underlying disease rapidly is important but not easy. Although B-type natriuretic peptide (BNP) is generally accepted as a useful marker, inconclusive results require an emergency physician (EP) to have something more confirmative. We evaluate whether Tissue Doppler Echocardiography (TDE) performed by an EP can better discriminate between heart disease and lung disease than can BNP in the emergency department (ED). METHODS: For enrolled ED patients with acute dyspnea and unclear pathology, initial BNP level and TDE performed by EP were checked prospectively. The ratios of peak early diastolic transmitral blood flow velocity (E) versus the peak early diastolic tissue velocity over mitral annulus (Ea) on TDE were recorded. The sensitivity and specificity of tissue Doppler parameters and BNP levels for diagnosing acute heart failure were calculated and we compared the discriminatory ability of the two tools. RESULTS:49 patients (39 heart failure, 10 respiratory disease) were enrolled. The area under the ROC curves for BNP and E/Ea were 0.946 and 0.888 (p<0.001) respectively. Cutoff values were 350 pg/ml for BNP (sensitivity and specificity of 82.1% and 100%) and 9.0 for E/Ea (89.2% and 100%). Especially in the group with low BNP (<350), BNP was a poor discriminator of the underlying disease, whereas E/Ea was still effective (AUC: 0.943, p=0.021). CONCLUSION: TDE by EP is a useful tool for diagnosing acute heart failure in ED and could easily and rapidly discriminate the underlying disease of acutely dyspneic patients, especially in patients with inconclusive BNP levels.

Emergency Abdominal Ultrasonography for Differential Diagnosis of Acute Abdominal Pain : COUCH (Complaint-oriented Ultrasonography with CHecklist) approach

PURPOSE: The purpose of this study was to verify objectively whether abdominal ultrasonography performed by emergency physicians (EP) in emergency departments (ED) immediately after history taking and physical examination could give effective diagnostic information and to check the feasibility and usefulness of the COUCH method. METHODS: From May 1, 2005 to September 30, 2005 we recruited 368 patients who complained of abdominal pain in the ED. Senior level emergency physicians (EP) conducted history taking and physical examinations, following which they were asked for their suspected diagnosis and their level of confidence (from maximum 5 to minimum 1) regarding each diagnosis. The same EP then performed abdominal ultrasonography (US), using the COUCH method and were again asked for their suspected diagnosis and level of confidence. We compared the suspected diagnoses and levels of confidence before and after abdominal US by using the t-test. RESULTS: A total of 106 patients (55 male, 51 female, average age 35.46+/-18.11 years) were enrolled. The number of patients with a suspected diagnosis of after history taking and physical examination only (2.43+/-0.5) was significantly greater than after abdominal US (1.34+/-0.5) (p<0.01). The level of confidences of suspected diagnosis of after history taking and physical examination only (3.43+/-1.14), by contrast, was less than after abdominal US (4.40+/-1.22) (p<0.01). Each year of postgraduate residents could have the same results after US. CONCLUSION: We found that abdominal ultrasonography could give EP more informations for pronouncing a correct diagnosis for patients with abdominal pain in the ED, and the COUCH method could lead the EP to get better training for ultrasonography and to diagnose more rapidly and accurately.

The Utility of Emergency Ultrasound for Diagnosing Wrist and Ankle Injuries

PURPOSE: Ultrasound is of proven accuracy in abdominal and thoracic trauma and may be useful for diagnosing extremity injury in situations where radiography is not available, such as disasters and military and space applications. However, the diagnosis of fractures is suggested by history and physical examination and is typically confirmed with radiography. As a alternative to radiography, we prospectively evaluated the utility of extremity ultrasound performed by trained residents of emergency medicine (EM) one patient with wrist and ankle extremity injuries. METHODS: Initially, residents of EM performed physical examinations for fractures. The emergency ultrasound (EM US) was performed by trained residents, who used a portable ultrasound device with a 10- to 5-MHz linear transducer, on suspected patients before radiography examination. The results of emergency ultrasound and radiography and the final diagnosis were recorded, and correlations among them were determined by using Kappa`s test. RESULTS: Thirty-nine patients were enrolled in our study. The average age was 36.6+/-19.3 years. There were radius Fx. (n=21), radius-ulna Fx. (n=1), ulna Fx. (n=1), and contusion (n=2) injuries among the wrist injury and lat.-med. malleolar Fx. (n=13), lat. malleolar Fx. (n=6), and med. malleolar Fx. (n=3) injuries among the ankle injury. Comparing EM US with radiography, we found the sensitivity, specificity, positive predictive value, and negative predictive value of EM US for Fx. diagnosis to be 100%, 66.7%, 97.3%, 100% and those of radiography to be 97.2%, 100%, 100%, and 75%, respectively. Kappa`s test for a correlation between the Fx. diagnosis of EM US and the final diagnosis of Fx was performed, and Kappa`s value was 0.787 (P = 0.004). CONCLUSION: EM US for Fx. can be performed quickly and accurately by EM residents with excellent accuracy in remote locations such as disaster areas and in military and aerospace applications. EM US was as useful as radiography in our study and had a high correlation to the final diagnosis of Fx. Therefore, ultrasound should performed on patients with extremity injury to determine whether extremity evaluation should be added to the FAST (focused abdominal sonography trauma) examination.

Initial Unmeasured Anions on Emergency Department in Critically ill Patients: Can they Predict the Morbidity?

PURPOSE: To determine whether initial corrected anion gap (C(o)AG), base excess caused by unmeasured anions (BEua), and strong ion gap (SIG) can predict the morbidity of critically ill patients admitted to emergency department (ED). METHODS: 138 patients who visited the critical section of the ED and were admitted to intensive care unit (ICU) were enrolled. We calculated the C(o)AG, BEua, and SIG from the initial blood samples of the patients and initial logistic organ dysfunction score (LODS) also. Then we measured the LODS at the last day of ICU stay again. Comparing with the initial LODS, we divided the patients into two groups based on the changes of the values: favorable group and poor group. RESULTS: There was a significant difference in the mean AGcorr (p=0.007), BEua (p=0.008), SIG (p=0.037) between favorable and poor group. The area under the receiver operating characteristic (AUROC) curves for morbidity prediction were relatively small: 0.66 (95% CI, 0.56-0.77) for C(o)AG, 0.65 (95% CI, 0.54-0.76) for BEua, and 0.59 (95% CI, 0.49-0.70) for SIG. CONCLUSION: We found the initial unmeasured anions at the ED of the patients who eventually showed improved LODS during ICU period are significantly different to those of the other patients. But they failed to show enough capability of discriminating the morbidities between two groups.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.

The Change of the Optic Nerve Sheath Diameter (ONSD) Following Treatment in Patients with Increased ICP

PURPOSE: Many reports have shown that the optic nerve sheath diameter (ONSD) can be measured easily by ultrasonography, and that it becomes wider when the intra-cranial pressure (ICP) is increased. However, there have been no reports comparing the two ONSDs following proper treatment. We measured the 2nd ONSDs of patients who were diagnosed with intra-cranial hemorrhage and increased ICP and who were admitted to an intensive care unit following management of their conditions, and analyzed the changes of the ONSDs and their relationship to the outcomes. METHODS: During the 10 months beginning December 1, 2004, we recruited 29 patients who were suspected to have increased ICP as indicated by computed tomography at the emergency center. Meeting any one of the following criteria was defined as elevated ICP: mid-line shifting of 3 mm or greater due to mass effect; a collapsed 3rd ventricle; hydrocephalus; effacement of sulci with significant edema; abnormal mesencephalic cisterns. We determined initial ONSDs by ultraonography and the Glasgow Coma Scale (GCS). At the 7th hospital day, GCS and ONSDs were re-evaluated and compared against the previous data. RESULTS: 29 patients (21 male, 8 female, average age 55.55 years) were enrolled. Mean GCS at the admission was 7.86+/-3.60. 18 patients had spontaneous hemorrhage (62%) and 11 patients had traumatic hemorrhage (38%). 22 patients received emergency surgery, 18 patients (62%) showed improved neurological outcomes and 11 (38%) failed to achieve any good outcomes. The initial mean ONSD was 5.41+/-0.70 mm. The average ONSD for traumatic hemorrhage (5.51+/-0.45 mm) was not statistically different from the ONSD for non-traumatic hemorrhage (5.35+/-0.84 mm) (p=0.55). The mean ONSD after 7 days of admission was 4.41+/-0.53 mm, which represented a significant decrease compared with the initial measurements (p<0.05). The mean GCS and ONSD showed significant differences between the improved group and the nonimproved group (GCS: 13.44+/-2.15, 3.82+/-3.82 respectively; and ONSD: 4.13+/-0.40 mm, 4.86+/-0.37 mm respectively; p<0.05). CONCLUSION : Among the patients with increased ICP, the ONSDs who progressed to good neurological outcomes after treatment had a significantly smaller diameter than those of the others. Through measurement of the ONSDs using ultrasonography, we could not only predict increased ICP but also determine the correlation between a patient's ICP and clinical course.