High-pressure injection hand injury: What lies beneath?

ABSTRACT: High-pressure injection injuries are true emergencies that require prompt treatment to avoid devastating complications. This article describes the presentation and management of these injuries and provides clear and concise recommendations for intervention by the ED clinician.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders.

INTRODUCTION: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. METHODS: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. RESULTS: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. CONCLUSION: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Visually guided male urinary catheterization: a feasibility study.

INTRODUCTION: Ten percent to 15% of urinary catheterizations involve complications. New techniques to reduce risks and pain are indicated. This study examines the feasibility and safety of male urinary catheterization by nursing personnel using a visually guided device in a clinical setting. METHODS: The device, a 0.6-mm fiber-optic bundle inside a 14F triple-lumen flexible urinary catheter with a lubricious coating, irrigation port, and angled tip, connects to a camera, allowing real-time viewing of progress on a color monitor. Two emergency nurses were trained to use the device. Male patients 18 years or older presenting to the emergency department with an indication for urinary catheterization using a standard Foley or Coudé catheter were eligible to participate in the study. Exclusion criteria were a current suprapubic tube or gross hematuria prior to the procedure. Twenty-five patients were enrolled. Data collected included success of placement, total procedure time, pre-procedure pain and maximum pain during the procedure, gross hematuria, abnormalities or injuries identified if catheterization failed, occurrence of and reason for equipment failures, and number of passes required for placement. RESULTS: All catheters were successfully placed. The median number of passes required was 1. For all but one patient, procedure time was ≤ 17 minutes. A median increase in pain scores of 1 point from baseline to the maximum was reported. Gross hematuria was observed in 2 patients. DISCUSSION: The success rate for placement of a Foley catheter with the visually guided device was 100%, indicating its safety, accuracy, and feasibility in a clinical setting. Minimal pain was associated with the procedure.

A systematic review and meta-analysis of diagnostic screening criteria for blunt cerebrovascular injuries.

BACKGROUND: Despite progress in diagnosing and managing blunt cerebrovascular injury (BCVI), controversy remains regarding the appropriate population to screen. A systematic review of published literature was conducted to summarize the overall incidence of BCVI and the various screening criteria used to detect BCVI. A meta-analysis was performed to evaluate which screening criteria may be associated with BCVI. Goals were to confirm inclusion of certain criteria in current screening protocols and possibly eliminate criteria not associated with BCVI. STUDY DESIGN: Studies published between January 1995 and April 2011 using digital subtraction angiography or CT angiography as a diagnostic modality and reporting overall BCVI incidence or prevalence of BCVI for specific screening criteria were examined. Screening criteria were analyzed using a random effects model to determine if an association with BCVI was present. RESULTS: The incidence range of BCVI was between 0.18% and 2.70% among approximately 122,176 blunt trauma admissions. The meta-analysis encompassed 418 BCVI and 22,568 non-BCVI patients. Of the 9 screening criteria analyzed, cervical spine (odds ratio [OR] 5.45; 95% CI 2.24 to 13.27; p < 0.0001) and thoracic (OR 1.98; 95% CI 1.35 to 2.92; p = 0.001) injuries demonstrated a significant association with BCVI. CONCLUSIONS: Patients with cervical spine and thoracic injuries had significantly greater likelihoods of BCVI compared with patients without these injuries. All patients with either injury should be screened for BCVI. Multivariate logistic regression analysis is needed to elucidate the possible impact of the combined presence of screening criteria, but it was not possible in our study due to limitations in data presentation. Standardized reporting of BCVI data is not established and is recommended to permit future collaboration.

Current trends in the management of difficult urinary catheterizations.

Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. Improper insertion of catheters also can significantly increase healthcare costs due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in the management of the patient with acute urinary retention, including attending emergency physicians who often are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm for the management of difficult urinary catheterizations that incorporates technology enabling direct visualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients.

Does a category II trauma activation warrant the initial presence of an attending trauma surgeon?

BACKGROUND: Previous studies have examined the impact of the immediate presence of attending trauma surgeons on category I trauma alert activation outcomes. STUDY OBJECTIVES: This study sought to determine if the initial presence of an attending surgeon influences category II trauma activation outcomes. METHODS: This 2-year retrospective review of category II alert activations involved a trauma database query to identify patients and extract pertinent variables. RESULTS: The attending and non-attending groups were comprised of 2192 (67.6%) and 1051 (32.4%) patients, respectively. There was no significant difference in gender, age, emergency department (ED) duration, Intensive Care Unit (ICU) duration, ED disposition, or ICU admission between groups. No significant differences in outcomes, including patient mortality, complication rates, length of stay, and Injury Severity Score, were calculated between groups. CONCLUSION: These results lend strength to our category II trauma alert activation criteria and suggest that non-critically injured patients in need of trauma care are receiving appropriate treatment, regardless of who performs the initial evaluation. Comparable successful outcomes support the contention that the mandatory initial presence of an attending trauma surgeon is not necessary for category II activations. Initial evaluation may be performed by an emergency physician alone or by a non-attending surgeon (senior surgical resident or fellow) in conjunction with an emergency physician. Management of category II trauma alert activations should be determined by individual institutions after a thorough evaluation of resources and outcomes.