Rib Fracture Diagnosis in the Panscan Era Murphy, Charles E., MD; Raja, Ali S., MD, MPH; Baumann, Brigitte M., MD, MSCE ...
Annals of emergency medicine,
12/2017, Letnik:
70, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Study objective With increased use of chest computed tomography (CT) in trauma evaluation, traditional teachings in regard to rib fracture morbidity and mortality may no longer be accurate. We seek ...to determine rates of rib fracture observed on chest CT only; admission and mortality of patients with isolated rib fractures, rib fractures observed on CT only, and first or second rib fractures; and first or second rib fracture–associated great vessel injury. Methods We conducted a planned secondary analysis of 2 prospectively enrolled cohorts of the National Emergency X-Radiography Utilization Study chest studies, which evaluated patients with blunt trauma who were older than 14 years and received chest imaging in the emergency department. We defined rib fractures and other thoracic injuries according to CT reports and followed patients through their hospital course to determine outcomes. Results Of 8,661 patients who had both chest radiograph and chest CT, 2,071 (23.9%) had rib fractures, and rib fractures were observed on chest CT only in 1,368 cases (66.1%). Rib fracture patients had higher admission rates (88.7% versus 45.8%; mean difference 42.9%; 95% confidence interval CI 41.4% to 44.4%) and mortality (5.6% versus 2.7%; mean difference 2.9%; 95% CI 1.8% to 4.0%) than patients without rib fracture. The mortality of patients with rib fracture observed on chest CT only was not statistically significantly different from that of patients with fractures also observed on chest radiograph (4.8% versus 5.7%; mean difference –0.9%; 95% CI –3.1% to 1.1%). Patients with first or second rib fractures had significantly higher mortality (7.4% versus 4.1%; mean difference 3.3%; 95% CI 0.2% to 7.1%) and prevalence of concomitant great vessel injury (2.8% versus 0.6%; mean difference 2.2%; 95% CI 0.6% to 4.9%) than patients with fractures of ribs 3 to 12, and the odds ratio of great vessel injury with first or second rib fracture was 4.4 (95% CI 1.8 to 10.4). Conclusion Under trauma imaging protocols that commonly incorporate chest CT, two thirds of rib fractures were observed on chest CT only. Patients with rib fractures had higher admission rates and mortality than those without rib fractures. First or second rib fractures were associated with significantly higher mortality and great vessel injury.
Current guidelines for treating cardiac arrest recommend administering 1 mg of epinephrine every 3−5 min. However, this interval is based solely on expert opinion. We aimed to investigate the impact ...of the epinephrine administration interval (EAI) on resuscitation outcomes in adults with cardiac arrest. We systematically reviewed the PubMed, EMBASE, and Scopus databases. We included studies comparing different EAIs in adult cardiac arrest patients with reported neurological outcomes. Pooled estimates were calculated using the IVhet meta-analysis, and the heterogeneities were assessed using Q and I2 statistics. We evaluated the study risk of bias and overall quality using validated bias assessment tools. Three studies were included. All were classified as “good quality” studies. Only two reported the primary outcome. Compared with a recommended EAI of 3−5 min, a favorable neurological outcome was not significantly different in patients with the other frequencies: for <3 min, odds ratio (OR) 1.93 (95% CI: 0.82−4.54); for >5 min, OR 1.01 (95% CI: 0.55−1.87). For survival to hospital discharge, administering epinephrine for less than 3 min was not associated with a good outcome (OR 1.66, 95% CI: 0.89−3.10). Moreover, EAI of >5 min did not pose a benefit (OR 0.87, 95% CI: 0.68−1.11). Our review showed that EAI during CPR was not associated with better hospital outcomes. Further clinical trials are necessary to determine the optimal dosing interval for epinephrine in adults with cardiac arrest.
The CRASH-2 trial demonstrated that tranexamic acid (TXA) reduced mortality with no increase in adverse events in severely injured adults. TXA has since been widely used in injured adults worldwide. ...Our objective was to estimate mortality and adverse events in adults with trauma receiving TXA in studies published after the CRASH-2 trial.
We systematically searched PubMed, Embase, MicroMedex, and ClinicalTrials.gov for studies that included injured adults who received TXA and reported mortality and/or adverse events. Two reviewers independently assessed study eligibility, abstracted data, and assessed the risk of bias. We conducted meta-analyses using random effects models to estimate the incidence of mortality at 28 or 30 days and in-hospital thrombotic events.
We included 19 studies and 13 studies in the systematic review and meta-analyses, respectively. The pooled incidence of mortality at 28 or 30 days (five studies, 1538 patients) was 10.1% (95% confidence interval CI, 7.8-12.4%) (vs 14.5% 95% CI, 13.9-15.2% in the CRASH-2 trial), and the pooled incidence of in-hospital thrombotic events (nine studies, 1656 patients) was 5.9% (95% CI, 3.3-8.5%) (vs 2.0% 95% CI, 1.8-2.3% in the CRASH-2 trial).
Compared to the CRASH-2 trial, adult trauma patients receiving TXA identified in our systematic review had a lower incidence of mortality at 28 or 30 days, but a higher incidence of in-hospital thrombotic events. Our findings neither support nor refute the findings of the CRASH-2 trial but suggest that incidence rates in adults with trauma in settings outside of the CRASH-2 trial may be different than those observed in the CRASH-2 trial.
Abstract Objective The antifibrinolytic agent tranexamic acid (TXA) has demonstrated clinical benefit in trauma patients with severe bleeding, but its effectiveness in patients with traumatic brain ...injury (TBI) is unclear. We conducted a systematic review to evaluate the following research question: In ED patients with or at risk of intracranial hemorrhage (ICH) secondary to TBI, does TXA compared to placebo improve patients' outcomes? Methods MEDLINE, EMBASE, CINAHL, and other databases were searched for randomized controlled trial (RCT) or quasi-RCT studies that compared the effect of TXA to placebo on outcomes of TBI patients. The main outcomes of interest included mortality, neurologic function, hematoma expansion, and adverse effects. We used “Grading quality of evidence and strength of recommendations” to assess the quality of trials. Two authors independently abstracted data using a data collection form. Results from studies were pooled when appropriate. Results Of 1030 references identified through the search, 2 high-quality RCTs met inclusion criteria. The effect of TXA on mortality had a pooled relative risk of 0.64 (95% confidence interval CI, 0.41-1.02); on unfavorable functional status, a relative risk of 0.77 (95% CI, 0.59-1.02); and on ICH progression, a relative risk of 0.76 (95% CI, 0.58-0.98). No serious adverse effects (such as thromboembolic events) associated with TXA group were reported in the included trials. Conclusion Pooled results from the 2 RCTs demonstrated statistically significant reduction in ICH progression with TXA and a nonstatistically significant improvement of clinical outcomes in ED patients with TBI. Further evidence is required to support its routine use in patients with TBI.
A search for dark matter was conducted by looking for an annual modulation signal due to the Earth's rotation around the Sun using XMASS, a single phase liquid xenon detector. The data used for this ...analysis was 359.2 live days times 832 kg of exposure accumulated between November 2013 and March 2015. When we assume Weakly Interacting Massive Particle (WIMP) dark matter elastically scattering on the target nuclei, the exclusion upper limit of the WIMP–nucleon cross section 4.3×10−41 cm2 at 8 GeV/c2 was obtained and we exclude almost all the DAMA/LIBRA allowed region in the 6 to 16 GeV/c2 range at ∼10−40 cm2. The result of a simple modulation analysis, without assuming any specific dark matter model but including electron/γ events, showed a slight negative amplitude. The p-values obtained with two independent analyses are 0.014 and 0.068 for null hypothesis, respectively. We obtained 90% C.L. upper bounds that can be used to test various models. This is the first extensive annual modulation search probing this region with an exposure comparable to DAMA/LIBRA.
A search for the neutrinoless quadruple beta decay of 136Xe was conducted with the liquid-xenon detector XMASS-I using 327 kg ×800.0 days of the exposure. The pulse shape discrimination based on the ...scintillation decay time constant which distinguishes γ-rays including the signal and β-rays was used to enhance the search sensitivity. No significant signal excess was observed from the energy spectrum fitting with precise background evaluation, and we set a lower limit of the half life of 3.7 × 1024 years at 90% confidence level. This is the first experimental constraint of the neutrinoless quadruple beta decay of 136Xe.
Trauma is the leading cause of death and disability in children in the USA. Tranexamic acid (TXA) reduces the blood transfusion requirements in adults and children during surgery. Several studies ...have evaluated TXA in adults with hemorrhagic trauma, but no randomized controlled trials have occurred in children with trauma. We propose a Bayesian adaptive clinical trial to investigate TXA in children with brain and/or torso hemorrhagic trauma.
We designed a double-blind, Bayesian adaptive clinical trial that will enroll up to 2000 patients. We extend the traditional E
dose-response model to incorporate a hierarchical structure so multiple doses of TXA can be evaluated in different injury populations (isolated head injury, isolated torso injury, or both head and torso injury). Up to 3 doses of TXA (15 mg/kg, 30 mg/kg, and 45 mg/kg bolus doses) will be compared to placebo. Equal allocation between placebo, 15 mg/kg, and 30 mg/kg will be used for an initial period within each injury group. Depending on the dose-response curve, the 45 mg/kg arm may open in an injury group if there is a trend towards increasing efficacy based on the observed relationship using the data from the lower doses. Response-adaptive randomization allows each injury group to differ in allocation proportions of TXA so an optimal dose can be identified for each injury group. Frequent interim stopping periods are included to evaluate efficacy and futility. The statistical design is evaluated through extensive simulations to determine the operating characteristics in several plausible scenarios. This trial achieves adequate power in each injury group.
This trial design evaluating TXA in pediatric hemorrhagic trauma allows for three separate injury populations to be analyzed and compared within a single study framework. Individual conclusions regarding optimal dosing of TXA can be made within each injury group. Identifying the optimal dose of TXA, if any, for various injury types in childhood may reduce death and disability.
We present the result of an indirect search for high energy neutrinos from Weakly Interacting Massive Particle (WIMP) annihilation in the Sun using upward-going muon (upmu) events at ...Super-Kamiokande. Data sets from SKI-SKIII (3109.6 days) were used for the analysis. We looked for an excess of neutrino signal from the Sun as compared with the expected atmospheric neutrino background in three upmu categories: stopping, non-showering, and showering. No significant excess was observed. The 90% C.L. upper limits of upmu flux induced by WIMPs of 100 GeV c-2 were 6.4 X 10--15 cm--2 s--1 and 4.0 X 10--15 cm--2 s--1 for the soft and hard annihilation channels, respectively. These limits correspond to upper limits of 4.5 X 10--39 cm--2 and 2.7 X 10--40 cm--2 for spin-dependent WIMP-nucleon scattering cross sections in the soft and hard annihilation channels, respectively.
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