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Some notes from last week’s conference:

If Dr. Hill’s presentation on benchmarking, and where our fine hospital(s) and EDs stand in the scheme of things, please get involved. The regular Operations meetings are a good start. Also, if you enjoyed Dr. Baumlin’s brief segment on Ibex (Picis) and coding of charts, well, there are many ways to pursue your interest.

Termination of Resuscitation is an interesting topic that we don’t talk enough about. Lisa mentioned Morrison’s 2006 validation of a TOR rule in NEJM (PMID: 16885551) — the rule being for EMTs with AED training, that resuscitation should be stopped in out-of-hospital cardiac arrest if there is no ROSC, no shocks administered, and no EMS-witnessed arrest. This multicenter trial of 1240 adults would have terminated resus on 776 patients — four of which ended up surviving (three with good neuro outcomes). So this rule’s PPV is 99.5% but there’s a least a few people alive today who are glad it’s not universally applied.

We have new faculty with an interest in appropriate resuscitation — see abstracts here and here.

I’d like to dwell for a moment on a part of Dr. Montagna’s presentation on pediatric trauma — previously I hadn’t spent much time on learning skull films, based on the 2002 ACEP TBI imaging policy. The new 2008 guidelines don’t have much to say on skull films, either:

In this revision, the first question about the role of plain film radiographs was not readdressed because the panel concluded that there is no new evidence that changes the recommendation made in 2002:

Recommendation B: Skull film radiographs are not recommended in the evaluation of mild TBI. Although the presence of a skull fracture increases the likelihood of an intracranial lesion, its sensitivity is not sufficient to be a useful screening test. Indeed, negative findings on skull films may mislead the clinician.

But this is for adults. In kids, skull films in kids under two years of age with a big subcutaneous hematoma may be an effective screening tool that spares the child a lot of radiation. This 2005 review (PMID: 16133604) agrees that skull films still have a place in our practice:

They still have some use with focal, depressed, skull fractures but are especially useful in evaluating skull fractures in the battered child syndrome. The CT study does not always provide as graphic a depiction of the fractures as do plain skull films. This is important, because in the battered child syndrome one needs to explain mechanism of injury, and this is best done with analysis of the fractures on plain films. Plain films also are useful in the evaluation of patients with shunts for hydrocephalus. Detection of breaks, kinks, etc. in the shunt tubing is mostly a plain-film task. At the same time one can get an idea as to the presence of increased intracranial pressure if one should also see spreading of the sutures, especially the coronal suture.

Beyond the images in the above paper, the web has some resources on skull films here, here and here. And if you enjoyed Dr. Montagna’s talk on C-spine radiography, especially the part on pseudosubluxation, please refer to this excellent 2003 review (PMID: 12740460).

Also, if you want to simplify the peds tetanus vaccine schedule in your mind: if a kid is older than 8 or 9 but not yet in high school, and has a dirty wound, give a tetanus shot. If they’re under 4-5 they probably haven’t completed their regimen and also deserve a shot.

Young spoke very well about altered mental status and procedural sedation in his pediatric M+M. I don’t have too much to add now (especially since I’ll be tackling the same topic shortly) but when he mentioned famed neurologist Vladimir Kernig, well, I just wanted to note we covered him and his sign in the Journal Club blog, now over two years ago. Although TB meningitis is almost unheard of now, and so the usefulness of Kernig’s sign is not clear, I’m told one of our colleagues is researching the Jolt sign…

As for Dr. Bruns’ talk on wound management, I was hoping to find some videos online about corner or stellate lac repair technique, but so far no videos. NEJM does have a primer on basic repair, and Roberts + Hedges has great descriptions on technique. If you’re interested in the saving time, money and frustration, there’s good evidence to support tap water over sterile saline for wound irrigation ( Acad Emerg Med. 2007 May;14(5):404-9), and nonsterile over sterile gloves (Ann Emerg Med. 2004
Mar;43(3):362-70) for ED lac repairs (in uncomplicated, non-immunocompromised patients, naturally).

Very soon in journal club we’ll be discussing abscess management in more detail. Here’s the NEJM primer (video, pdf). One of you mentioned a reference to the dangers of packing abscesses with tape — if any of you could supply me with the reference I’d be grateful.

Posted on Tuesday, September 2nd, 2008 at 12:10 am by Nick. Filed under Post-Conference Letter, Trauma, Meningitis, Procedures, Blog.
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