Journal of Emergency Medicine, Trauma and Acute Care - Volume 2015, Issue 1

Benign paroxysmal positional vertigo (BPPV) is an extremely common cause of peripheral vertigo. BPPV is believed to be caused by the presence of tiny crystals in the semicircular canals. It is typically diagnosed from a patient's history and examination.

A 55-year-old lady dialed the emergency services due to severe vertigo and vomiting for about two hours. The previous night she travelled around 250 miles in her caravan to North Wales, UK, for a holiday. No ambulance was available to be dispatched, hence the ambulance control contacted the local general practitioner doctor on duty to attend to the patient. The patient was suffering from recurrent vertigo symptoms for nearly two years, despite being on medications. She described her symptoms as room spinning when she wanted to get out of the bed which was associated with vomiting. History and examination revealed no signs attributing to acute stroke.

After performing the Dix-Hallpike test, the doctor confirmed the diagnosis of posterior canal BPPV and the patient was offered the modified Epley maneuver. Post-maneuver, a significant improvement in her symptoms was noticed within a few minutes. On arrival of ambulance crew after an hour, the patient decided not to go to hospital as her symptoms were almost 90 percent better. This case highlights the need for awareness among family medicine and emergency doctors to diagnose and treat BPPV with a physical maneuver rather than medications.

Background: The prevalence of abdominal aortic aneurysm (AAA) is 1-2 percent in the general population, and is as high as 6 percent in groups with risk factors. Objectives: The aim of this study was to determine the prevalence of AAA amongst high-risk cardiac patients in the emergency department (ED). Methods: A prospective study was conducted to evaluate the prevalence of AAA in a high-risk population presenting to the ED. Inclusion criteria included male gender, Caucasian race, age over 50 years, history of smoking, and presentation to the ED with chest pain requiring admission. Patients enrolled in the study were screened for AAA by ultrasound (US) scan. Study subjects were excluded if there was inadequate imaging. Results: One hundred and nine patients were recruited into the study. Nineteen patients were excluded by the ED US Director secondary to inadequate imaging. Of the remaining 90 patients, eight patients were found to have AAA (n = 8; 8.9%; CI 3.9 - 16.8%). Of the eight patients with an AAA, four had diagnosed cardiovascular disease during their hospital admission. There was no statistically significant difference in secondary risk factors such as hypertension, diabetes, dyslipidemia or previous history of coronary artery disease between those with AAA and those without AAA. Conclusions: This study found that in a single ED, the prevalence of AAA in high-risk cardiac patients admitted to rule out acute coronary syndrome who could be adequately visualized with ultrasound was over 8 percent. With such a high prevalence, this population could be a potential screening group.

Inferior epigastric vessel (IEV) bleeding usually results in a localised rectus sheath haematoma. This condition was thought to be uncommon and sometimes overlooked or misdiagnosed. Lately the condition has become more prevalent with life threatening bleeding which may need emergency intervention to save life. A case report of IEV bleeding following trauma in a 17-year-old male is reported. A CT scan enabled localisation of the injury site and showed signs of active bleeding. Facilities for embolization didn't exist in the hospital at the time. The bleeding was life threatening which required an emergency laparotomy.

The laparotomy confirmed the source of the bleeding as the left IEV. The offending vessel was ligated and the haematoma was evacuated. The patient recovered well and his life was saved. Bleeding from the IEV is thought to be rare and the result is usually a haematoma which can be treated conservatively. The presentation is changing and there is an increase in severity and frequency of the bleeding which can endanger life. If facilities for embolization do exist, a minimally invasive procedure is the method of choice. If on the other hand they don't exist, which is the case in many hospitals; laparotomy should be performed where there is a threat to life.

Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.

Background: The objective of this study was to assess the current numbers-based model of evaluation of emergency medicine residents in emergency ultrasound, specifically by focusing on the proficiency of residents to interpret right upper quadrant, focused abdominal sonogram for trauma, abdominal aorta, first trimester pregnancy, and cardiac scans. Methods: A prospective analysis of emergency medicine residents' competency in emergency ultrasound was conducted in 2009 and 2010. Residents completed a multiple choice style examination primarily assessing residents' diagnostic accuracy. The accuracy and confidence of diagnosis for each resident based on the examinations were compared to his/her training level and number of scans per application completed prior to testing, in order to assess the relationship of experience to competence. Results: Thirty-six emergency medicine residents, postgraduate year 1–3 (n = 15, 8, 13), were enrolled in the study and took the exam. There was a statistically significant relationship between the number of scans and mean exam score for right upper quadrant (p = 0.0013) and abdominal aorta (p = 0.0013) scans. Residents demonstrated a statistically significant improvement in scores at greater than 16 scans for right upper quadrant (p = 0.0018) and 13 scans for abdominal aorta (p = 0.0018). Conclusion: Adequate resident training for interpretation for certain applications such as right upper quadrant and abdominal aorta, may be achievable using smaller numbers than the generally accepted guideline of 25 scans per application. Additionally, the number of scans needed to reach competency may be variable dependent on the specific ultrasound application.

Background: Emergency Department (ED) analgesia can potentially be delivered quickly using transbuccal administration. A previous study identified time-of-onset advantage of a 100 mcg fentanyl buccal tablet (FBT) as compared to a dose of 5 mg oxycodone with 325 mg acetaminophen. The current study reports comparison of higher-dose (200 mcg) FBT as compared to a more commonly used oxycodone dose of 10 mg with 650 mg acetaminophen. Methods:Time frame: Patients were enrolled between October 2012 and October 2014.

Setting: The study was conducted in an urban teaching ED with annual census of 55,000.

Patients: The 50 convenience-sampled cases met eligibility criteria of age 18-60, with isolated orthopedic complaints; subjects required X-ray to rule-out fracture, and to have pain sufficient to warrant opioids.

Interventions: In this double-blind placebo-controlled analgesia trial, patients were randomized to one of two study groups. OXY subjects received two orally ingested tablets, each containing 5 mg oxycodone and 325 mg acetaminophen, and a transbuccal inactive comparator. FBT subjects received two placebo oral tablets and a 200 mcg FBT.

Data: The main study endpoint was achievement of at least two points' reduction in numeric pain rating scale (NPRS) within ten minutes of study drug administration. NPRS was assessed at the time of study entry and every five minutes' post-drug administration for an hour. Secondary endpoints included assessment of side effects and subjects' desire to have the same medication for future similar pain.

Analysis: Categorical data were assessed with binomial exact 95% confidence intervals (CIs). Continuous data, after being demonstrated as non-normal with skewness-kurtosis testing, were analyzed with Kruskal-Wallis testing. Multivariate Cox proportional hazards analysis was performed to assess whether, after adjustment for potential confounders, there was a difference between FBT and OXY groups with respect to time to achieving significant analgesia. Results: Study groups were similar with respect to age (medians: OXY 34, FBT 38, p = 0.47), initial pain score (median 8 in each group), sex (proportion of males: OXY 64%, FBT 48%, p = 0.25), and ethnicity (proportion of whites: OXY 68%, FBT 56%, p = 0.38). The same proportion (52%) of OXY and FBT cases achieved significant reduction in pain within 15 minutes. Multivariate Cox regression adjusting for potential confounders confirmed (p = 0.28) no difference in rates of pain reduction between OXY and FBT. There were no major complications in either group. The majority of subjects in each group (80% in FBT group versus 76% in OXY group, p = 0.73) expressed high satisfaction and preference to receive the same regimen in future. Conclusion: This study's results suggest approximate equivalence between 200 mcg FBT and 10 mg oxycodone with 650 mg acetaminophen, with respect to time-to-analgesia, analgesic efficacy, side effects, and patient satisfaction.

Intratonsillar abscesses are not uncommon. The reported incidence of unilateral tonsillar abscess is 5 percent. There have not been any cases of bilateral tonsillar involvement previously reported. The clinical presentation of intratonsillar abscess are similar to peritonsillar abscess. Negative aspiration of pus from a case of intratonsillar abscess presumed to be peritonsillar abscess can lead to misdiagnosis and subsequent delay in treatment. We report a case of a 42-year-old diabetic patient with odynophagia, dysphagia, voice change, stridor and fever for a duration of four days. CT scan was performed in view of trismus and neck swelling as the initial provisional diagnosis of deep neck abscesses was made. The CT scan showed bilateral intratonsillar abscesses without involvement of other neck spaces. ‘Hot’ tonsillectomy was immediately performed after which the patient recovered well. Although uncommon, a high index of suspicion is required to diagnose intratonsillar abscess, especially in patient groups with high-risk factor e.g., diabetes mellitus with severe clinical complications.

Background: Disaster medicine training in medical school is a key element of disaster preparedness, and several international educational authorities have called for an increase in this specific type of training. The objective of this study was to assess the current state of disaster medicine education in the Kingdom of Saudi Arabia. Methods: All 30 medical schools in Saudi Arabia were invited to participate in the study, and a 25-item online survey was sent to those that consented. Results: The response rate was 67%. Only three of the responding 20 universities currently have disaster medicine programs, and they spend an average of three hours per year on the subject. Respondents without disaster medicine curricula indicated that a mandatory, accredited course in the final three years of the six-year program was their preferred method for implementation, and most favored a blended approach. Conclusions: The study found that there is a paucity of disaster medicine programs in Saudi Arabia. Most schools indicated a willingness to implement such training in their undergraduate programs but cited lack of an adequate number of relevant professionals as a major impediment.

Bilateral temporomandibular joint (TMJ) dislocation is very rare in children with only three cases previously reported in the literature. We report a case of a 26-month-old female child who presented to the emergency department of a tertiary care hospital with complaints of inability to close her mouth and drooling of saliva for the last two hours. Clinical examination and X-ray of the TMJ revealed bilateral TMJ dislocation. Bilateral TMJ reduction was achieved with the Hippocratic method after giving analgesia and procedural sedation. The child was able to close her mouth post-reduction, and was discharged with post-TMJ reduction instructions given to the mother and with maxillofacial clinic follow up. Our report is the first case of a child presenting to the emergency department with bilateral TMJ dislocation.