Ketorolac versus meperidine: ED treatment of severe musculoskeletal low back pain.

The study objective was to assess the efficacy and patient acceptance of ketorolac as an alternative to meperidine for the treatment of severe musculoskeletal low back pain (LBP). A double blinded prospective trial in a convenience sample of patients >18 years of age presenting to an urban university hospital emergency department (ED) was conducted over a 19-month period. Patients were included if the pain was musculoskeletal in origin and was severe enough to warrant parenteral analgesics. Patients were randomized to receive 1 mg/kg meperidine intramuscularly (IM) or 60 mg ketorolac IM. Pain intensity was measured preadministration and at 60 minutes via a 100 mm Visual Analog Scale (VAS). Outcomes measured at 60 minutes were pain intensity decrease (PID), patient satisfaction, rescue analgesia requirement, sedation level, and adverse effects. Clinically significant pain reduction was defined as a PID of at least 13 mm or a reduction in pain of least 30%. One hundred fifty-five patients were enrolled (meperidine = 75, ketorolac = 80) and 153 patients completed the study. At 60 minutes the mean PID was 7 mm less in the ketorolac group (95% confidence interval [CI] - 15 mm to 2.6 mm). Pain reduction of at least 30% occurred in 63% of the ketorolac group versus 67% of the meperidine group (95% CI, odds ratio [OR] .43 to 1.61). Rescue analgesia was required in 35% of the ketorolac group versus 37% of the meperidine group (95% CI, OR .47 to 1.74). Patient satisfaction was less in the ketorolac group (ketorolac 68% satisfied versus meperidine 74% satisfied) however this was not significant (95% CI, OR .66 to 2.72). Sedation level and adverse effects were significantly greater in the meperidine group. Ketorolac shows comparable single dose analgesic efficacy to a single moderate dose of meperidine with less sedation and adverse effects in an ED population with severe musculoskeletal LBP. The trend for greater pain reduction and patient satisfaction with meperidine needs further investigation.

The integration of primary care sports medicine into an academic emergency medicine practice: academic and revenue enhancement.

OBJECTIVES: To determine whether integrating primary care sports medicine into academic emergency medicine (EM) can enhance both revenue and the academic program. METHODS: A retrospective descriptive review of all patients seen in a primary care sports medicine practice at a university hospital sports medicine clinic was done over a 24-month period. All patients seen initially in the ED for a sports injury either by the author or by another EM faculty member with follow-up by the author in the sports medicine clinic were included in the study group. The study group was analyzed for diagnoses, payor mix, and revenue generated by the ED follow-up sports medicine clinic visits. RESULTS: There were 199 patients who met the inclusion criteria. This resulted in 483 ED follow-up sports medicine clinic visits. The author practiced 13 hours/week in the ED and 16 hours/week in the primary care sports medicine practice, which resulted in 1,536 sports medicine clinic hours. The study group accounted for 20% of the total patient volume in the author's primary care sports medicine practice. There were 111 lower-extremity injuries (knee 52%, foot/ankle 40%, hip/pelvis 8%), 81 upper-extremity injuries (hand/wrist 48%, shoulder 43%, elbow 9%), and seven spine injuries. Payor mix was 47% traditional indemnity, 45% HMO, 4% self-pay, and 4% Medicare/Medicaid. Total charges for the ED follow-up sports medicine clinic visits were $44,767 ($92.68/visit) and net receipts were $30,276 ($62.68/visit). This represented 20% of the total charges and 16% of the net receipts in the author's sports medicine practice during this period. Revenue generated by the ED follow-up sports medicine clinic visits could have supported 12% of the equivalent cost of the base pay for a full-time EM faculty position. CONCLUSION: The integration of primary care sports medicine into an academic EM faculty practice can enhance revenue through the establishment of an ED follow-up sports medicine clinic while also providing an opportunity to expand resident learning experiences.

Forefoot pain in a young girl.

A 12-year-old girl struck her left foot against a wall during a school basketball game but continued to play, despite a minor injury. During the following days, she developed mild forefoot swelling and persistent discomfort in the foot. She presented to her primary care physician, and plain x-rays were unremarkable. She was diagnosed as having a foot sprain and was given no specific treatment.

Valgus knee instability in an adolescent: ligament sprain or physeal fracture?

A 15-year-old boy was hit on the lateral aspect of his left knee while playing football. The injury was initially diagnosed as a medial collateral ligament sprain, and radiographs were negative. Stress views, however, demonstrated medial widening of the physis consistent with a Salter-Harris type 1 injury to the distal femur, and magnetic resonance imaging (MRI) demonstrated a type 3 injury extending through the epiphysis. Stress radiographic views or MRI is diagnostic of distal femoral physeal fracture, and a positive diagnosis should prompt referral.

Baseball injuries: a Little League survey.

OBJECTIVES: To determine the patterns of injury in youth baseball and apply the data to estimate the value of proposed safety equipment. DESIGN: Prospective population-based injury survey. PARTICIPANTS: 2861 Little League baseball players (ages 7 to 18) for 140 932 player-hours. MEASUREMENTS: An injury was included in the data only if it was serious enough to require medical/dental care, caused missing a game, or disallowed playing a certain position. The injuries were subdivided into acute or overuse. The acute injuries were classified as either catastrophic, severe, or minor. Injuries were categorized according to mechanism, area injured, and whether the player was on offense or defense. RESULTS: There were 81 total injuries, of which 66 (81%) were acute and 15 (19%) were overuse. Of the acute injuries, 11 were severe and 55 were minor. The overall injury rate was .057 injuries per 100 player-hours. The severe injury rate was .008 injuries per 100 player-hours, of which 46% were ball-related injuries and 27% were collisions. The most frequent mechanism of injury was being hit by the ball, which represented 62% of the acute injuries. Of the 41 ball-related injuries, 28 (68%) occurred to players on defense. Of the 18 ball-related facial injuries, 16 occurred to players on defense. CONCLUSIONS: 1) Little League baseball is a safe activity with a low injury rate and a particularly low rate of severe injury; 2) impact by the ball causes more than half the acute injuries, thus safety interventions should be directed towards decreasing these injuries, especially on defense; and 3) facemasks on batters can safely eliminate facial injuries to offensive players, but would only moderately reduce the incidence of ball-related facial injuries as most of these injuries are sustained by defensive players.

Stabilization of rural multiple-trauma patients at level III emergency departments before transfer to a level I regional trauma center.

STUDY OBJECTIVE: To determine whether triage and stabilization of severely injured rural trauma victims in outlying Level III emergency departments before transfer to Level I trauma centers results in outcomes similar to national normative data. DESIGN: Retrospective review of trauma transfers and deaths during a 4-year period. SETTING: Two Level III EDs in rural, upstate New York and an urban Level I regional trauma center. PARTICIPANTS: Fifty multiple-trauma victims with a Trauma Triage Score (T-RTS) of < or = 11 or less. Forty-three patients were stabilized before transfer, and 7 died in the rural Level III ED. RESULTS: There were 45 blunt injuries and 5 penetrating injuries. Mean patient age was 34 years (range, 9 months to 97 years). The Revised Trauma Score (RTS) on admission to the Level III ED was calculated for each patient (median score, 5.97; interquartile range (IQR), 4.09 to 6.90), as was the ultimate Injury Severity Score (ISS) (median score, 23; IQR, 13 to 29). With TRISS methodology, probabilities of survival (Ps) and death (Pd) were calculated. Results were compared with the Major Trauma Outcome Study (MTOS) by use of current coefficients derived from Walker-Duncan regression analysis of MTOS data. The predicted number of deaths was 13.5, whereas the actual number was 12, Z statistic, -.710. There were two unexpected survivors and three unexpected deaths. The 43 patients who were stabilized and transferred had a median RTS of 5.97 (IQR, 4.30 to 6.90) and an ISS of 18 (IQR, 12 to 25). The median interval in the Level III ED before transfer was 1 hour 43 minutes (IQR, 1 hour 11 minutes to 2 hours 40 minutes). There were two unexpected survivors (Ps = .32, Ps = .49) and 1 unexpected death (Ps = .52). The predicted number of deaths was 8.1, whereas the actual number was 5. The 7 patients who died in the rural Level III ED had a median RTS of 4.41 (IQR, 2.98 to 4.71) and a median ISS of 50 (IQR, 44 to 65). The median interval in the Level III ED before death was 42 minutes (IQR, 41 minutes to 1 hour 20 minutes). There were 2 unexpected deaths (Ps = .66, Ps = .55). The predicted number of deaths was 5.4 whereas the actual number was 7. CONCLUSION: Triage and stabilization of severely injured rural trauma victims at Level III EDs before Level I transfer provide outcomes similar to national results. Unexpected death of severely injured trauma victims remains a problem in rural Level III EDs.

Strangulation associated with a passive restraint shoulder harness seatbelt: case report.

Diagonal shoulder harness restraint devices have been implicated as causes of neck trauma in motor vehicle accidents. This type of seatbelt is commonly used as an alternative to airbags in required passive restraint systems. A case of strangulation secondary to an automatically engaging diagonal shoulder harness used without the accompanying lap seatbelt is reported.