Does the U Stand for Useless? The Urine Drug Screen and Emergency Department Psychiatric Patients.

BACKGROUND: Behavioral emergencies account for a significant portion of emergency department (ED) visits in the United States. Substance abuse is common in this population and may precipitate or exacerbate preexisting psychiatric illness. Contrary to ED policy guidelines, many behavior health centers (BH) require a urine drug screen (UDS) in stable patients prior to transfer. OBJECTIVE: We sought to determine the role of the UDS in ED length of stay (LOS), cost, and charges to patients and inpatient psychiatric care. METHODS: We performed a retrospective chart review of all patients transferred to an in-network BH from September 1-30, 2014. Clinical data were extracted and analyzed from our electronic medical record, including records from both the ED visit and the BH stay. RESULTS: There were 205 patient encounters identified; 89 patients had a UDS performed in the ED and 89% were obtained after the ED medical clearance. LOS were similar between the two groups, however, time to ED departure from time of medical clearance was delayed in the UDS group. BH providers mentioned UDS results < 25% of the time and no confirmatory tests were performed. There was no difference in BH LOS or discharge diagnosis of substance-abuse disorder. Patient charges for UDS over the month totaled $21,093. CONCLUSION: The UDS did not seem to have any significant effect on inpatient psychiatric care; whereas ED LOS and cost were both negatively affected. Based on these results, the UDS seems to be of little-to-no benefit in the setting of acute psychiatric illness.

Management of inflammatory bowel disease flares in the emergency department [digest].

Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This issue reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support. [Points & Pearls is a digest of Emergency Medicine Practice.].

Management of inflammatory bowel disease flares in the emergency department

Because of the chronic relapsing nature of inflammatory bowel disease (IBD), emergency clinicians frequently manage patients with acute flares and complications. IBD patients present with an often-broad range of nonspecific signs and symptoms, and it is essential to differentiate a mild flare from a life-threatening intra-abdominal process. Recognizing extraintestinal manifestations and the presence of infection are critical. This issue reviews the literature on management of IBD flares in the emergency department, including laboratory testing, imaging, and identification of surgical emergencies, emphasizing the importance of coordination of care with specialists on treatment plans and offering patients resources for ongoing support.

Damage control in the management of ruptured abdominal aortic aneurysm: preliminary results.

BACKGROUND: This study compared damage control measures (DCM), including operative techniques (DCO) and resuscitative measures (DCR), with standard treatment (ST) for ruptured abdominal aortic aneurysm (rAAA). METHODS: Historical cohort study methodology was used to evaluate outcomes for rAAA repairs related to DCM or ST over a 74-month period at a level I trauma center. RESULTS: Of 28 repairs, 13 (46.4%) were DCM. Compared to ST patients, DCM patients had a lower mean preoperative BP (64.6 vs. 83.2 mm Hg, P = .03) and greater intraoperative blood loss (4.6 vs. 2.1 liters, P = .033). Patients who had both DCR and DCO (DCO & DCR) received more plasma (6.8 vs 2.6 units, P = .039) and less crystalloid (2.8 vs 10.5 liters, P = .005) than those receiving DCO only. A modest decrease in mortality was seen in the DCO & DCR group compared to DCO only. No DCO-related graft infections were observed. CONCLUSION: DCR use may prove beneficial in the management of rAAA.

Alcohol and high-risk behavior among young first-time offenders.

BACKGROUND: Underage drinking carries a high risk of injury. An important approach for reducing underage drinking is limiting youth access to alcohol. Underage drinkers obtain alcohol from multiple sources and patterns of access may vary by region. We examined patterns of access to alcohol and alcohol use among youth in a local court-ordered diversion program for first-time adolescent alcohol offenders as a basis for designing and evaluating community prevention efforts. METHODS: Youth in the program completed a survey of demographic data, type of offense, source, setting, and quantity of alcohol consumed at time of offense, and 1-year alcohol-related high-risk behaviors. Significance was attributed to p < or = 0.05. RESULTS: Completed surveys were obtained from 1,158 (84.8%) of 1,366 eligible participants during the 23-month study period. There were 71% males and 29% females with a mean age of 17.2 years (range, 12-24 years). Respondents were Caucasian (64.5%), Hispanic/Latino (19.9%), Asian (3.5%), African American (2.5%), and others (9.6%). Offenses included minor in possession (55.8%), driving under the influence (21.2%), and drunk in public (20.4%). Consumption at time of offense was one or less drinks in 36.3%, two to five drinks in 31.7%, and 32.0% reported six or more drinks. Social sources of alcohol (got it from someone else) were reported by 72.9% and commercial sources (bought it or took it from a store) were reported in 11.9%. The two most common places of consumption were someone else's home (30.7%) and the beach (14.6%). Multiple 1-year high-risk behaviors were reported and 41.0% drove after drinking or rode with someone else who had been drinking. Binge drinking (5 or more drinks for males; 4 or more drinks for females) was reported by 43.1% of males and 36.7% of females. All high-risk behaviors were more common in binge drinkers (p < 0.001). Drinking and driving or riding with a drinking driver was reported in 54.2% of those who binged. Females who binged reported a higher rate than males in 8 of 10 high-risk behaviors. CONCLUSIONS: This study revealed the predominance of social sources of alcohol among young first-time alcohol offenders. Drinking and driving or riding with a drinking driver was reported at an alarmingly high rate. Other alcohol-related high-risk behaviors were also common. Efforts to prevent alcohol-related trauma should target social access to alcohol, the resulting high-risk behaviors, and include a special focus on young females.

Preemptive craniectomy with craniotomy: what role in the management of severe traumatic brain injury?

BACKGROUND: Patients with severe traumatic brain injury (TBI) require aggressive management to prevent secondary brain injury. "Preemptive" craniectomy (CE)--craniectomy performed as a primary procedure in conjunction with craniotomy--has been used as prophylaxis for secondary injury, but the indications and outcomes of craniectomy used for this purpose are not well defined. METHODS: To evaluate the role of CE in the management of TBI, we retrospectively reviewed 62 consecutive patients who underwent CE in a 78-month period at our level I trauma center. A cohort of patients who underwent craniotomy only (CO) during this period was compared with the CE group for TBI patterns, indications for operation, and outcomes. Multivariable logistic regression and matched propensity score analysis were used to test the association between CE and survival. The rate of CE was determined by individual neurosurgeons. RESULTS: Of 197 patients with brain injuries who underwent craniotomy, 62 (31.5%) had CE and 135 (68.5%) had CO. Mean age for CE versus CO was 41 years versus 51 years (p < 0.01). Mean admission Glasgow Coma Score was lower in CE versus CO (7.6 vs. 11.8, p < 0.001); Injury Severity Score was higher (30.2 vs. 26.3, p < 0.01). The indication for operation for CE compared with CO was subdural hematoma in 41 (66.1%) versus 87 (64.4%, p = 0.82), epidural hematoma in 2 (3.2%) versus 26 (19.3%, p < 0.01), and cerebral contusion or hematoma in 15 (24.2%) versus 8 (5.9%, p < 0.001). Postoperative intracranial pressure was monitored in 48 (77.4%) CE and 44 (32.6%) CO patients (p < 0.001). Intracranial pressure <20 was maintained in 26 (54.2%) after CE and in 31 (70.5%) after CO (p = 0.12). In the CE group, 26 (42%) died compared with 31 (26%, p < 0.01) in the CO group. When adjusted for severity of injury, however, there was no significant difference in mortality between the two groups (p = 0.134). The CE rate obtained by a neurosurgeon varied from 8.6% to 75.0% (p < 0.001). CONCLUSION: CE was used in patients with more severe injuries, and particularly in those with more severe head injuries. When adjusted for injury severity, CE was not associated with worsened survival, and therefore may reasonably be included in the armamentarium of neurotrauma care. Use of CE by our neurosurgeons, however, varied significantly. These findings underscore the need for practice guidelines based on randomized trials to fully evaluate the role of CE in the management of TBI.