Prehospital Care of Severely Intoxicated Patients by a Dutch Physician-Staffed Helicopter Emergency Medical Services: A Retrospective Study.

OBJECTIVE: Intoxicated patients are often encountered by emergency medical services (eg, in cases of recreational drug use, accidental ingestion, or inhalation of toxic substances or [attempted] suicide). Earlier research showed that a physician-staffed helicopter emergency medical service (P-HEMS) is regularly dispatched for intoxicated patients. However, it is still unclear if there is added value of P-HEMS compared with standard care provided by an ambulance crew. The aim of this study was to analyze the contribution of additional expertise and equipment that P-HEMS brings to the prehospital scene. METHODS: In this retrospective study, we searched the database of the helicopter emergency medical service Lifeliner 1 serving the northwestern quadrant of the Netherlands for cases that involved intoxications from January 2013 to July 2020. Patients were included in this study if the primary reason for P-HEMS dispatch was intoxication. The types of intoxication were categorized as (illicit/recreational) drug related, suicide attempt, or accidental. The agents were categorized as stimulants, depressants, hallucinogenic, cannabinoids, and other substances such as bleach or insulin. Patient characteristics, vital signs, and the therapeutic interventions performed were recorded for analysis. RESULTS: In our study period, P-HEMS was dispatched 23,878 times. Of these dispatches, a total of 259 cases were included for further analysis. The majority of patients were male (64.5%). Sixty-six patients (25.5%) had an intoxication of depressant agents alone, whereas 60 patients (23.2%) had an intoxication with a combination of agents. With 159 (61.4%) patients, the majority of cases involved recreational drug intoxications. Unintentional intoxications were treated in 27 (10.4%) patients, whereas 73 (28.2%) cases involved suicide attempts. In 159 patients (61.4%), prehospital endotracheal intubation was required; the vast majority was performed by the helicopter emergency medical service physician. Specific antidotes were administered in 56 (21.6%) of the cases. CONCLUSION: In this study, we found that P-HEMS crews might complement usual prehospital care by ambulance crews for patients with severe intoxications by bringing advanced skills (eg, airway management and specific antidotes) to the scene.

Does the Lever Sign Test Have Added Value for Diagnosing Anterior Cruciate Ligament Ruptures?

BACKGROUND: Diagnosing an anterior cruciate ligament (ACL) rupture based on a physical examination remains a challenge for both surgeons and physical therapists. The lever sign test was developed to overcome the practical limitations of other tests and to optimize diagnosis. An evaluation of the measurement properties of the lever sign test is needed to make adequate interpretations in practice. PURPOSE: To evaluate the reliability and diagnostic value of the lever sign test. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 94 patients were recruited between November 2014 and July 2016. Patients were included if they were at least 16 years old, suffered from knee trauma, and had indications for knee arthroscopic surgery. Lever sign, anterior drawer, Lachman, and pivot-shift test outcomes were examined by an orthopaedic/trauma surgeon and a physical therapist. A test-retest design was used to investigate interrater reliability. Moreover, the lever sign test outcomes, alone and in combination with the other diagnostic tests, were compared with arthroscopic results, which served as the gold standard for the test's diagnostic value. RESULTS: The lever sign test and pivot-shift test had kappa values exceeding 0.80 for interrater reliability. The kappa values for the anterior drawer test and Lachman test were 0.80 and 0.77, respectively. The lever sign test showed the highest specificity (100%) and the lowest sensitivity (39%) when compared with the other 3 tests. Moreover, its positive and negative predictive values were 100% and 65%, respectively, while an accuracy of 71% was calculated. Clustering the lever sign test parallel with the other 3 tests resulted in the highest accuracy of 91%. CONCLUSION: The lever sign test appears to have high interrater reliability and is the most specific test, showing a maximal positive predictive value. A positive lever sign test result indicates an ACL rupture. These results support the added value of the lever sign test for diagnosing ACL ruptures.

ACL injury: How do the physical examination tests compare?

Three physical examination tests are most commonly used to evaluate cruciate ligament injury. The best known and most frequently used technique is the anterior drawer test. The other 2 tests, the Lachman test and the pivot shift test, are more difficult to perform and are used less often, especially by physicians untrained in their use. In addition, there is a relatively new diagnostic test: the lever sign test. The aim of our article is to provide a short, clinically relevant overview of the literature and to assess the diagnostic value of physical examination for the primary care physician.