Initial Presentation (http://www.medscape.com/viewarticle/583892_1)

Chief Complaint: Found unresponsive

History of Present Illness: The patient’s family found her unresponsive in her apartment. She was seen the day before and appeared “okay.”

History

Past Medical History: Diabetes; recent treatment for chronic heel ulceration with osteomyelitis

Family History: Hypertension

Physical Findings

Age: 40
Gender: Female
Blood Pressure: Systolic BP 50 mm Hg by palpation
Pulse: 44 bpm
General Appearance: Unresponsive
Cardiac Exam: Brady S₁, S₂

Dx Diagnosis

This electrocardiogram (ECG) is recorded in the emergency room (Figure 1).

Discussion

Sinus bradycardia and marked QT prolongation are present. What was initially thought to be ST elevation in the inferior leads is actually a notch at the end of the QRS complex called an Osborn J wave. A positive notch is seen in leads I, II, III, aVF, and V₆. Negative notches are present in V₁ and V₂. The deformity in the QRS complex in leads V₃, V₄, and V₅ might represent an enormous notch! Sinus bradycardia, not 2:1 AV block, is present. The QRS itself, save for the Osborn wave, is narrow. Osborn J waves are associated with hypothermia; it is said that the more profound the hypothermia, the larger the J waves. This patient’s temperature was reported to be 26.6°C (in August). What was the underlying problem? Diabetic ketoacidosis (DKA); blood sugar was 591, pH 6.68, HCO_3- < 5, K⁺ 2.7. She was aggressively treated with IV fluid, insulin, sodium bicarbonate, warming, and antibiotics. Her heel osteomyelitis had progressed to gangrene; this was thought to be the trigger for her DKA.

Treatment

Her metabolic parameters were aggressively treated. Sixteen hours later, all of the striking ECG findings had resolved. The patient made a full neurologic recovery; a below the knee amputation was performed for the foot gangrene.

Abstract:
Background: Routine laboratory and radiology panels as part of the initial evaluation of the trauma patient are prevalent practices. This is a study of utility and cost effectiveness of this practice.

Methods: During a 3-month period, trauma panels were analyzed for cost and impact on patient care in our institution.

Results: Four hundred ten consecutive patients had 3,982 studies (cost $417,839) performed of which 1,292 (cost $114,753) were abnormal and only 253 (cost $36,703) were clinically contributory.

Conclusions: Routine panels are not useful or cost effective. Negative results contribute little to management. Selective and targeted studies should be indicated by the secondary survey, and may result in substantial cost savings ($1,500,000 per year at our institution).

Abstract:
Background: Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI.

Methods: All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI.

Results: In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001.

Conclusions: Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

Abstract:
Background: Although an early diagnosis is crucial to optimize outcomes after injury to the anterior cruciate ligament (ACL), little is known about the performance of emergency room physicians in diagnosing this injury.

Hypothesis: We hypothesized that emergency room physicians would miss a substantial proportion of ACL ruptures.

Study: Prospective comparative study.

Methods: From April 2004 through October 2004, all patients aged 15 to 55 years and presenting at the emergency department of a teaching hospital for acute knee injury without fracture or multiple injuries were included. The results of a standardized examination conducted by the emergency physicians were compared with the findings by a sports medicine specialist 5 +/- 2 days later. Magnetic resonance imaging was performed when the specialist found a positive Lachman’s test and was used as the reference standard for diagnosing ACL rupture. Cohen’s kappa test was used to evaluate agreement between emergency physicians and the specialist.

Results: Of the 79 included patients, 27 (34.2%) had a diagnosis of ACL rupture established by the specialist and confirmed by magnetic resonance imaging. Agreement was poor between emergency physicians and the sports medicine specialist regarding popping sound, instability, joint effusion, a positive Lachman’s test, and a diagnosis of ACL rupture. Emergency physicians diagnosed only 7 of the 27 ACL ruptures.

Conclusion: Emergency physicians missed a substantial proportion of acute ACL ruptures. Efforts are needed to improve their skills in diagnosing ACL rupture.

Abstract:
Background: Thoracolumbar spine (TLS) fractures are rare in the pediatric population but may result in significant morbidity, necessitating a prompt diagnosis. No formal recommendations have been made for screening pediatric trauma patients for TLS fractures; early diagnosis has traditionally relied on clinical parameters extrapolated from adult data.

Methods: From March 2004 to April 2005 patients presenting to a level one pediatric trauma center were consecutively enrolled. Clinicians were asked to assess eligible patients and prospectively state their TLS examination findings and degree of clinical suspicion for fracture.

Results: A total of 228 patients were enrolled (mean age of 8.2 years), 16 with TLS fractures. Clinical performance of the TLS spine examination diagnosed a fracture with a sensitivity of 81% (95% CI: 0.57, 0.93), specificity of 68% (0.62, 0.74), and odds ratio of 9.38 (2.59, 34.01). A clinician’s degree of suspicion detected a TLS fracture with a sensitivity of 56% (95% CI: 0.33, 0.77), specificity of 82% (0.77, 0.87), and odds ratio of 6.08 (2.13, 17.37).

Conclusions: The clinician is able to clinically diagnose TLS fractures in pediatric trauma patients with good sensitivity and average specificity, however, TLS fractures were missed. Screening radiographs may still be required until larger studies confirm these findings.