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1.
Background
Elbow dislocations are one of the most common large joint dislocations and they require urgent reduction in the emergency department. Posterior dislocations are the most common type, with anterior dislocations occurring in rare cases.Discussion
Reduction techniques include traction–countertraction, patient-assisted countertraction, the leverage approach, and the modified Stimson technique. Complications can include nerve injury, vascular injury, and compartment syndrome.Conclusions
It is important for emergency physicians to be familiar with several different reduction techniques for elbow dislocations in case the initial reduction attempt is unsuccessful. This article reviews the current evidence for reduction of elbow dislocations and any variations on these approaches. 相似文献2.
Background
Luxatio erecta humeri or inferior dislocation of the glenohumeral joint is a rare presentation in the emergency department that is typically caused by a direct loading force on a fully abducted arm. This type of shoulder dislocation represents only 0.5% of all shoulder dislocations, making bilateral cases even more unique.Objective
The authors report a case of bilateral luxatio erecta to highlight some of the key clinical signs and discuss proper methods of care.Case Report
We report a case of bilateral luxatio erecta after a forward fall on a treadmill in a senior male patient. The patient grabbed onto the side rails of the treadmill such that his abducted arms received the entire force of the fall. These injuries were successfully reduced in the emergency department of our institution using a two-step approach for each: 1) conversion to anterior dislocation and 2) full reduction.Conclusions
Although shoulder dislocations remain a commonly seen injury in the emergency department, it is important to consider that not all dislocations are simply anterior. Signature signs of luxatio erecta are fixed abduction at the shoulder with elbow flexion and forearm pronation. The humeral head should be palpable inferior to the glenoid fossa. The most effective treatments for this injury involve sufficient muscle relaxation for reduction, a methodical approach to reduction, and appropriate immobilization. 相似文献3.
Background
Posterior sternoclavicular dislocations can be challenging diagnostically, as traumatic force often happens to the lateral shoulder rather than directly to the sternoclavicular joint. Shoulder radiographs do not illustrate the sternoclavicular joint well, and can miss the diagnosis. This injury, however, has the potential for life-threatening complications due to proximity of mediastinal structures that might also be injured.Case Report
The following case illustrates a delayed diagnosis of posterior sternoclavicular dislocation. It also shows how point-of-care ultrasound can diagnose a dislocation, confirm persistence of a dislocation diagnosis when patients are transported from a referring facility, as well as educate the patient and family.Why Should an Emergency Physician Be Aware of This?
Point-of-care ultrasound can be used to rapidly diagnose posterior sternoclavicular dislocations and to provide patients education about their injury. 相似文献4.
Lane Thaut Wells Weymouth Branden Hunsaker Daniel Reschke 《The Journal of emergency medicine》2019,56(1):23-28
Background
Central vein catheter (CVC) placement using the modified Seldinger technique is a common procedure in the emergency department, but can be time consuming due to the multiple pieces of equipment included in central line kits and the number of steps in the procedure. Preassembled devices combine a needle, guidewire, dilator, and sheath into one unit and potentially simplify the process and reduce time required for CVC placement using the accelerated Seldinger technique.Objective
Our aim was to evaluate whether the use of combination central line devices and the accelerated Seldinger technique will reduce the time required to place a CVC and increase the ease of the procedure.Methods
This two-arm randomized crossover study comparing the accelerated Seldinger technique to the modified Seldinger technique was performed in a simulation setting. Subjects were selected from among emergency physicians, emergency medicine residents, interns, physician assistants, and medical students. Subjects were timed using the modified and accelerated Seldinger techniques. Ease of use and satisfaction data were collected after both procedures.Results
The use of the accelerated Seldinger technique with a combination CVC device was significantly faster compared to the modified Seldinger technique with a standard CVC kit. Procedure time was reduced by 35% (p = 0.001), and ease of use was increased by 7% (p = 0.046), without any increase in errors.Conclusions
In the simulated setting, the accelerated Seldinger technique using combination CVC devices is a faster and easier method for CVC placement compared to the modified Seldinger technique. 相似文献5.
6.
Jacob G. McPherson Arno H. Stienen Justin M. Drogos Julius P. Dewald 《Archives of physical medicine and rehabilitation》2018,99(3):491-500
Objective
To systematically characterize the effect of flexion synergy expression on the manifestation of elbow flexor stretch reflexes poststroke, and to relate these findings to elbow flexor stretch reflexes in individuals without neurologic injury.Design
Controlled cohort study.Setting
Academic medical center.Participants
Participants (N=20) included individuals with chronic hemiparetic stroke (n=10) and a convenience sample of individuals without neurologic or musculoskeletal injury (n=10).Interventions
Participants with stroke were interfaced with a robotic device that precisely manipulated flexion synergy expression (by regulating shoulder abduction loading) while delivering controlled elbow extension perturbations over a wide range of velocities. This device was also used to elicit elbow flexor stretch reflexes during volitional elbow flexor activation, both in the cohort of individuals with stroke and in a control cohort. In both cases, the amplitude of volitional elbow flexor preactivation was matched to that generated involuntarily during flexion synergy expression.Main Outcome Measures
The amplitude of short- and long-latency stretch reflexes in the biceps brachii, assessed by electromyography, and expressed as a function of background muscle activation and stretch velocity.Results
Increased shoulder abduction loading potentiated elbow flexor stretch reflexes via flexion synergy expression in the paretic arm. Compared with stretch reflexes in individuals without neurologic injury, paretic reflexes were larger at rest but were approximately equal to control muscles at matched levels of preactivation.Conclusions
Because flexion synergy expression modifies stretch reflexes in involved muscles, interventions that reduce flexion synergy expression may confer the added benefit of reducing spasticity during functional use of the arm. 相似文献7.
Jenaro A. Fernández-Valencia Jordi CuñeJose M. Casulleres PhD Ana CarreñoSalvio Prat PhD MD 《The American journal of emergency medicine》2009
Background
The Spaso technique has been recently described as a new, simple, and effective manoeuvre for reducing anterior shoulder dislocation. However, there is a lack of series in the English literature. The aim of the study was to evaluate the results obtained with the introduction of this technique in an emergency department.Methods
An observational prospective study at the Hospital Clínic of Barcelona Orthopaedic Emergency Department was done from January 2007 to May 2007. In this period, the Spaso technique was applied in 36 anterior shoulder dislocations. Two of the patients were excluded due to a presentation later than 24 hours after the dislocation, leaving a total of 34 dislocations in 33 patients. They occurred in 22 male and 12 female shoulders. The patients' ages ranged from 21 to 80 years (average, 51 years). The success of the attempt, complications, and other data were collected.Results
The Spaso technique was successful in 23 (67.6%) of the 34 anterior shoulder dislocations. If just those patients with previous shoulder dislocations were taken into account, the success rate increased to 83%. No complications were observed.Conclusion
Based on the results of the present study, we consider the Spaso technique as a safe and effective manoeuvre for the reduction of anterior shoulder dislocations, with an acceptable success rate similar to the classical techniques previously described. 相似文献8.
Mustafa Uslu Mehmet Arican Ayhan Saritas Ramazan Buyukkaya Hayati Kandis 《世界急诊医学杂志(英文)》2012,3(4):311-313
BACKGROUND:
Traumatic bilateral hip dislocation is a rare condition. Anterior shoulder dislocation combined with this condition is even a rare occurrence. A 57-year-old man had bilateral asymmetric hip dislocation with a posterior wall fracture of the left acetabulum associated with right shoulder anterior dislocation caused by falling down from a cherry tree. Traumatic hip dislocation and anterior shoulder dislocation represent a true orthopedic emergency.METHODS:
Closed reduction was performed immediately for three of the dislocated joints. Posterior wall fracture of the left acetabulum was treated with open reduction and internal fixation by screws. Because of the severity of associated complications like aseptic necrosis or posttraumatic osteoarthritis, efforts were made to ensure prompt diagnosis, therapy and prognosis.RESULTS:
The patient was successfully treated by open reduction and internal fixation of the left acetabulum, and discharged from the hospital.CONCLUSION:
Traumatic asymmetric hip dislocation and anterior shoulder dislocation are an orthopedic emergency and early diagnosis with immediate reduction of the dislocation is the key determinants of excellent result of treatment.KEY WORDS: Trauma, Asymmetric hip dislocation, Shoulder dislocation, Immediate therapy 相似文献9.
Itai Shavit Danielle Shavit Oren Feldman Nir Samuel Anat Ilivitzki Daniel M. Cohen 《The Journal of emergency medicine》2019,56(1):29-35
Background
Ileocolic intussusception is a major cause for intestinal obstruction in early childhood. Reduction of intussusception, in the vast majority of institutions, is performed on awake children, without sedation.Objective
The aim of this study was to report the course of the first patients who were sedated by emergency physicians for pneumatic reduction of intussusception (PRI).Methods
We conducted a case series analysis of prospectively collected data on patients undergoing PRI, using a sedation recording tool. This tool uses standardized definitions from the Quebec guidelines for terminology and reporting adverse events in emergency medicine. Recording of time interval measurements and adverse events was performed by the emergency physician and nurse.Results
Between February 2016 and March 2018, 11 males and 3 females, with a median age of 11 months (interquartile range [IQR] 6–20 months), underwent sedation for PRI by five attending pediatric emergency physicians. All of the reductions were successful and without complications. Eight patients received ketamine and propofol, 5 received ketamine, and 1 received ketamine and midazolam. Median times for the presedation phase, procedure, sedation, physiologic recovery and emergency department recovery were: 131 min (IQR 79–104 min), 10.5 min (IQR, 9–12 min), 21 min (IQR, 20–30 min), 25 min (IQR, 23–30 min), and 108 min (IQR, 82–161 min), respectively. Four respiratory adverse events that required intervention were recorded. All were effectively treated with airway repositioning, suctioning, oxygen administration, or bag-mask ventilation.Conclusions
The first series of patients sedated for PRI by emergency physicians is reported. Our initial findings suggest the feasibility of emergency physician–administered sedation for PRI. 相似文献10.
Victoria L. Zhou Frances S. Shofer Nikita G. Desai Ilona S. Lorincz Nikhil K. Mull David H. Adler John C. Greenwood 《The Journal of emergency medicine》2019,56(2):127-134
Background
The resuscitation and critical care unit is a novel emergency department–intensive care unit designed to provide early critical care to emergency department patients for ≤24 h.Objectives
This study sought to identify clinical variables associated with short intensive care unit (ICU) stays in patients with diabetic ketoacidosis (DKA), who commonly require ICU-level care.Methods
We conducted a retrospective, single-center, cross-sectional study of DKA patients ≥18 years of age who presented to an academic, urban hospital emergency department over 16 months. Patient demographics and clinical variables extracted from medical records were compared between prolonged ICU stay patients of ≥24 h versus short ICU stay patients (SSPs) of <24 h. ICU care was defined as treatment in the resuscitation and critical care unit or inpatient ICU.Results
One hundred sixty-eight emergency department visits with a primary diagnosis of DKA were analyzed. There were 53 prolonged ICU stay patients, 58 SSPs, and 57 patients required no ICU time. SSPs had significantly higher initial serum bicarbonate (13.0 vs. 9.0 mEq/L, p = 0.01) and shorter anion gap closure time (9.8 vs. 14.4 hours, p = 0.003). Medication nonadherence was a significantly more frequent precipitant in SSPs (67.2% vs. 47.2%, p = 0.03). Initial anion gap, glucose, beta-hydroxybutyrate, and severity of illness scores were not significantly different between groups. After multivariate logistic regression adjusting for variables significant from univariate analysis, higher initial bicarbonate (p = 0.04) and medication nonadherence (p = 0.03) remained significantly associated with SSPs.Conclusions
Patients with DKA with short ICU stays have higher initial bicarbonate levels and are more likely to have medication nonadherence than patients requiring prolonged critical care. These variables may identify patients with DKA who are best treated in an emergency department–intensive care unit to potentially reduce inpatient ICU use. 相似文献11.
Objectives
To assess the combination of propofol and remifentanil for sedation to reduce shoulder dislocations in an ED.Methods
Eleven patients with anterior glenohumeral dislocation were given propofol 0.5 mg/kg and remifentanil 0.5 μg/kg iv over 90 seconds and then further doses of 0.25 mg/kg and 0.25μg/kg, respectively, if needed. Another practitioner attempted reduction using the Milch technique.Results
Reduction was achieved in all patients within four minutes of giving sedation (range 0.3–4; mean 1.6). Seven required one attempt at shoulder reduction, three required two attempts, and one required three attempts. Mean time to recovery of alert status was three minutes (range 1–6). The mean pain score during the reduction was 1.7 out of 10 (range 0–5). Nine patients had full recall, one had partial recall, and one had no recall at all. Eight patients were “very satisfied” with the sedation and three were “satisfied”. There were no respiratory or haemodynamic complications that required treatment.Conclusions
Propofol and remifentanil provide excellent sedation and analgesia for the reduction of anterior glenohumeral dislocation, enabling rapid recovery. 相似文献12.
Meng-Ting Lin Ching-Fang Chiang Chueh-Hung Wu Yi-Ting Huang Yu-Kang Tu Tyng-Guey Wang 《Archives of physical medicine and rehabilitation》2019,100(2):336-349.e15
Objective
To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis.Data Sources
PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017.Study Selection
We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis.Data Extraction
The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement.Data Synthesis
Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84).Conclusions
For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted. 相似文献13.
Tyler Snoap Matthew Jaykel Cayla Williams Jason Roberts 《The Journal of emergency medicine》2017,52(1):28-33
Background
Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis.Objective
To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting.Discussion
Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope.Conclusion
Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture. 相似文献14.
Michael V. Nguyen 《The Journal of emergency medicine》2019,56(1):46-52
Background
The treatment of orbital compartment syndrome has a rich history rooted in surgery and emergency medicine. It is a rare but acute and vision-threatening condition that most commonly occurs secondary to facial trauma or as a postoperative complication, and was first recognized in 1950. Surgical techniques and medical management were developed and refined soon afterwards to eventually become the modern-day treatment, lateral canthotomy, and inferior cantholysis.Objective
This article details the history of orbital compartment syndrome and the evolution of its treatment to the present day.Discussion
Given the time-sensitive nature and acuity of orbital compartment syndrome, lateral canthotomy was adopted by emergency physicians who could perform it more quickly at the bedside.Conclusions
Lateral canthotomy is a procedure adopted by emergency physicians from the surgical literature. The history of its adoption is a representative example of how emergency medicine evolves as a field. 相似文献15.
Taylor W. Burkholder Oliwier Dziadkowiec Kelly Bookman Renee A. King 《The Journal of emergency medicine》2019,56(1):7-14
Background
During the 2014 West African Ebola Virus Disease (EVD) outbreak, the U.S. Centers for Disease Control and Prevention recommended that all emergency department (ED) patients undergo travel screening for risk factors of importing EVD.Objectives
We sought to determine the overall adherence rate to the recommended travel screening protocol and to identify factors associated with nonadherence to the protocol.Methods
We conducted a multicenter, retrospective analysis of adherence to the travel screening program in an academic hospital and three affiliated community hospitals. A regression model identified patient and hospital factors associated with nonadherence.Results
Of the 147,062 patients included for analysis, 93.7% (n = 137,834) had travel screenings completed. We identified several characteristics of patients that were most likely to be missed by the screening protocol—patients with low English proficiency, patients who arrive via ambulance or helicopter, and patients with more severe illness or injury based on initial triage acuity.Conclusions
These findings should be used to improve adherence to the travel screening protocol for future emerging infectious disease threats. 相似文献16.
Backgrounds
One form of abnormal scapular alignment is scapular downward rotation (SDR). Changes in muscle function in SDR have not been clearly identified, and SDR exercises also require investigation. Although a diagonal pattern of exercise is commonly used as part of the exercise protocol, a direct comparison of shoulder and scapular diagonal exercises has not yet been conducted. The objectives of this study were to determine the altered activation of the scapular musculature in the SDR group and to investigate which diagonal pattern of exercise effectively activates the scapular musculature.Methods
Thirty-two participants (18 in the control group and 14 in the SDR group) volunteered to participate in this study. Electromyographic signals were collected from four muscles, the upper trapezius (UT), lower trapezius (LT), serratus anterior (SA), and anterior deltoid (AD), during standing performance of diagonal shoulder and scapular exercises.Results
The control group showed significantly lower UT activity, UT/LT ratio, and UT/SA values than the SDR group (p?<?.05). Activation of the AD was significantly higher in the SDR than in the control group (p?<?.05). SA and AD activation were significantly higher in shoulder diagonal pattern exercises than in scapular diagonal pattern exercises (p?<?.05). The scapular posterior elevation pattern exercise showed significantly higher UT and LT activities than anterior elevation and shoulder diagonal pattern exercises (p?<?.05).Conclusion
Our findings suggest that reduced activation of the UT could lead to greater activation in the AD in SDR. Scapular posterior elevation exercise is advantageous as selectively activates the trapezius musculature, and shoulder diagonal pattern exercise is advantageous in activating the SA and AD. 相似文献17.
Shinichi Fukuhara Tomohiro Sameshima Hidetoshi Matsuo Tamaki Ohashi 《The Journal of emergency medicine》2019,56(5):536-539
Background
Although fractures of the sternum are rare in young children, owing to the compliance of the chest wall, these fractures are still possible and require thorough examination. We present a case that emphasizes the usefulness of point-of-care ultrasound in the diagnosis of a pediatric sternal fracture complicated by a subcutaneous abscess.Case Report
A 5-year-old boy presented with tenderness of the sternum, with diffuse swelling extending bilaterally to the anterior chest wall. Ultrasound imaging identified irregular alignment of the sternum with a subcutaneous abscess and swirling of purulent material within the abscess in the fracture area. These findings were confirmed on enhanced chest computed tomography and had not been visible at the time of the first evaluation 6 days prior.Why Should an Emergency Physician Be Aware of This?
Our case demonstrates the usefulness of point-of-care ultrasound for the diagnosis and appropriate management of a sternal fracture complicated by a subcutaneous abscess in a young child. As ultrasound imaging is easy to perform at the bedside, it is useful for examining pediatric patients with swelling of the anterior chest and local tenderness of the sternum to rule out a sternal fracture, even if these fractures are deemed to be uncommon in children. 相似文献18.
Ashley S. Mogul David M. Cline Jennifer Gabbard Casey Bryant 《The Journal of emergency medicine》2019,56(2):145-152
Background
Early integration of palliative care from the emergency department (ED) is an underutilized care modality with potential benefits, but few studies have identified who is appropriate for such care.Objective
Our hypothesis is that patients aged 65 years or older who present to the ED as level I Emergency Severity Index from a long-term care (LTC) facility have high resource utilization and mortality and may benefit from early palliative care involvement.Methods
We performed a retrospective chart review of patients aged 65 years or older who arrived in the ED of an academic suburban southeastern level I trauma center from an LTC facility and triaged as level I priority. The ED course, hospital course, and final outcomes were analyzed.Results
Of the 198 patients studied, 54% were deceased 30 days after discharge, with only 29.8% alive at 12 months. Admitted patients had a median hospital length of stay of 5 days and 73% required intensive care. Formal palliative care intervention was provided in 40.4%, occuring a median of 4 days into hospitalization and leading to 85% downgrading their advanced directive wishes, and discharge occuring a median of 1 day later. Few formal palliative care interventions occurred in the ED (9.1%).Conclusions
Elderly patients from LTC facilities presenting with severe acute illness have high mortality and seldom receive early palliative care. Introduction of palliative care has the ability to change the course of treatment in this vulnerable population and should be considered early in the hospitalization and, where available, be initiated in the ED. 相似文献19.
Winora Conchita Gomes Kavitha Vishal Ganesh Balthillaya 《Journal of bodywork and movement therapies》2019,23(1):183-188
Objective
To compare the effects of the application of therapeutic heat and cold on the mechanical response of the median nerve neurodynamic testing.Design
Single-blinded randomized crossover trial.Methodology
56 asymptomatic university students (mean age?=?21.82?±?1.64 years) of either gender with a limited elbow extension range of motion during a Median Neurodynamic Test 1 were recruited. Each subject was administered 3 testing conditions on separate days with a 24-hr washout period. The interventions included 1) therapeutic moist heat around the elbow, 2) therapeutic cold around the elbow and 3) no thermal agent as a controlled condition. Outcome measure of elbow extension range of motion at the onset of pain and submaximal pain were recorded before the intervention, immediately after the removal of the thermal agents (20th min) and at 2 subsequent readings of 30 min and 1?hour after the removal of the thermal agent.Results
There was a significant effect of using a thermal agent with time on the elbow range of motion at the onset of pain [F(2,165)?=?3.622, p?=?0.029] and submaximal pain[F(2,165)?=?3.841, p?=?0.023] at the 20th min. A posthoc comparison indicated that at the 20th min the mean elbow range at the onset of pain and submaximal pain for the therapeutic heat condition (mean?=?33.5, S.D?=?13.37 and mean?=?16.80, S.D?=?12.99 respectively) was significantly different than the no thermal agent condition (mean?=?40.17, S.D?=?12.34 and mean?=?23.4, S.D?=?13.82 respectively). However, therapeutic cold condition did not significantly differ from both the other conditions.Conclusion
Therapeutic heat causes an immediate increase in elbow extension range of motion during a Median Neurodynamic Test1 and testing post the application of thermal agents can alter the test response. 相似文献20.