The Case of an Ugly Truth

  The great tragedy of Science — the slaying of a beautiful hypothesis by an ugly fact.                                                                             […]

EMCrit by Rory Spiegel.

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Capnography Across the Continuum of Care

See the Capnostream™ 35 portable respiratory monitor in multiple patient care environments. Brought to you by Medtronic.

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Traumatic inferior shoulder dislocation: a review of management and outcome

Abstract

Introduction

Traumatic inferior shoulder dislocation (ISD) is rare, estimated to occur in 0.5% of all shoulder dislocations. We describe the demographics, natural history and outcome of this injury.

Hypothesis/aim

The aim of the study is to provide a summary of the demographics, clinical presentation, management and outcome of patients who suffer ISD

Methods

We conducted a systematic review of the English language literature on ISD using PubMed, Medline, CINHAL, Cochrane Database and Evidence-Based Medicine Reviews. Articles were examined independently by two of the authors and data were extracted using a standard form. Descriptive statistics were performed.

Results

199 patients were identified, from 101 articles. Mean age was 44 years (range 13–94 years). All cases were caused by trauma, with falls accounting for 44% of all cases. There were three reported cases (2%) of open dislocations and 29 cases (15%) of bilateral ISD. Proximal humerus and scapular fractures were reported in 39 and 8% of patients, respectively. Neurological injury after dislocation was noted in 58 patients (29%). Vascular injury was noted in 20 patients (10%), which included axillary arterial injury in 19 patients and an upper limb deep vein thrombosis in one patient. Follow-up data were available for 107 patients (54%), with an average duration of 2.7 years (1 week–32 years). Avascular necrosis (AVN) was noted between 8 weeks and 2 years after initial injury in three patients (1.5%).

Conclusion

Clinical and radiographic assessment of ISD is key to diagnosis and successful reduction. Patients can be treated with shoulder immobilisation for 2–3 weeks. In the setting of ongoing pain or instability, further imaging should be performed. The outcome of ISD is generally favourable.

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Decompression of tension pneumothoraces in Asian trauma patients: greater success with lateral approach and longer catheter lengths based on computed tomography chest wall measurements

Abstract

Introduction

Our study aims to compare the anterior and lateral approaches for needle thoracostomy (NT) and determine the adequacy of catheter lengths used for NT in Asian trauma patients based on computed tomography chest wall measurements.

Methodology

A retrospective review of chest computed tomography scans of 583 Singaporean trauma patients during period of 2011–2015 was conducted. Four measurements of chest wall thickness (CWT) were taken at the second intercostal space, midclavicular line and fifth intercostal space, midaxillary line bilaterally. Measurements were from the superficial skin layer of the chest wall to the pleural space. Successful NT was defined radiologically as CWT ≤ 5 cm.

Results

There were 593 eligible subjects. Mean age was 49.1 years (49.1 ± 21.0). Majority were males (77.0%) and Chinese (70.2%). Mean CWT for the anterior approach was 4.04 cm (CI 3.19–4.68) on the left and 3.92 cm (CI 3.17–4.63) on the right. Mean CWT for the lateral approach was 3.52 cm (CI 2.52–4.36) on the left, and 3.62 cm (CI 3.65–4.48) on the right. Mean CWT was shorter in the lateral approach by 0.52 cm on the left and 0.30 cm on the right (p = 0.001). With a 5.0 cm catheter in the anterior approach, 925 out of 1186 sites (78.8%) will have adequate NT as compared to 98.2% with a 7.0 cm catheter. Similarly, in the lateral approach 1046 out of 1186 (88.2%) will have adequate NT as compared to 98.5% with a 7.0 cm catheter. Obese subjects had significantly higher mean CWT in both approaches (p = 0.001). There was moderate correlation between BMI and CWT in the anterior approach, r ² = 0.529 as compared to the lateral approach, r ² = 0.244.

Conclusion

Needle decompression using the lateral approach or a longer catheter is more likely to succeed in Asian trauma patients. A high BMI is an independent predictor of failure of NT, especially for the anterior as compared to lateral approach.

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EMCrit Podcast 209 – GTD Redux – Opportunities, Time, & Future Selves

More on GTD

EMCrit by Scott Weingart.

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EMCrit Podcast 209 – GTD Redux – Opportunities, Time, & Future Selves

More on GTD

EMCrit by Scott Weingart.

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Communicating Value in Simulation: Cost Benefit Analysis and Return on Investment

Abstract

Value-based health care requires a balancing of medical outcomes with economic value. Administrators need to understand both the clinical and economic effects of potentially expensive simulation programs to rationalize the costs. Given the often-disparate priorities of clinical educators relative to health care administrators, justifying the value of simulation requires the use of economic analyses few physicians have been trained to conduct. Clinical educators need to be able to present thorough economic analyses demonstrating returns on investment and cost effectiveness to effectively communicate with administrators.

At the 2017 Academic Emergency Medicine Consensus Conference “Catalyzing System Change through Health Care Simulation: Systems, Competency, and Outcomes”, our breakout session critically evaluated the cost benefit and return on investment of simulation. In this paper we provide an overview of some of the economic tools that a clinician may use to present the value of simulation training to financial officers and other administrators in the economic terms they understand. We also define three themes as a call to action for research related to cost benefit analysis in simulation as well as four specific research questions that will help guide educators and hospital leadership to make decisions on the value of simulation for their system or program.

This article is protected by copyright. All rights reserved.

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