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Introduction: Many traumatic pneumothoraces (PTX) are not seen on initial chest radiograph (CR) (occult PTX) but are detected only on computed tomography (CT). Although CR remains the first tool for detecting PTX, most trauma patients with significant thoracoabdominal injuries will receive both CT and CR. The primary objective of this study was to retrospectively determine the effectiveness of CR for detecting PTX in trauma patients. Our hypotheses were that CR is a sensitive indicator of PTX on CT, that chest pain and shortness of breath are good predictors of PTX on CR, and that we could determine other predictors of PTX on CR.Methods: All trauma patients presenting to our Level I trauma center with a CT-diagnosed PTX over a 2-year period who had both a CR and a chest CT were included. The CT reading was considered the gold standard for PTX diagnosis. Electronic medical records were searched using key words for diagnoses, symptoms, demographics, and radiologic results. We recorded the official radiologist readings for both CR and CT (positive or negative) and the size of the PTX on CT (large, moderate, small, or tiny). The outcome variable was dichotomized based on presence or absence of PTX detected on CR. Descriptive statistics and v2 tests were used for univariate analysis. A regressionanalysis was performed to determine characteristics predictive of a PTX on CR, and 1 variable was added to the model for every 10 positive CRs. With equal-size groups, this study has the power of 80% to detect a 10% absolute difference in single predictors of PTX on CR with 45 subjects in each group.Results: There were 134 CT-documented PTXs included in the study. Mean age was 42, and 74% were men. For 66 (49%) patients, PTX was detected on CR (sensitivity¼50%). The CR detected 30% of small PTX, 35% of moderate PTX, and 33% of large PTX. Comparing patients with and without PTX on CR, there were no significant differences in shortness of breath or chest pain. There no relationships between PTX detected on CR and age, gender, penetrating versus blunt injury, bilaterality of the PTX, or presence of lung contusion or hemothorax on CT. After adjusting for all significant variables, predictor of a PTX detected on CR was air in the tissue on CR (adjusted odds ratio [OR]¼3.8) and PTX size (compared to a tiny PTX, adjusted OR¼2.0 for a small PTX, 7.5 for a moderate PTX, and 51 for a large PTX). Chest tubes were used in 89% of patients with PTX on CR and 44% of patients with PTX only on CT (difference 45%; 95% confidence interval 30, 58).Conclusion: Factors associated with PTX on CR included air in the soft tissue on CR and size of the PTX. Even when PTX is not apparent on CR, 44% of these PTXs received placement of a chest tube. [West J Emerg Med. 2012;13(5):437–443.]

We wanted to prospectively evaluate the use of a brief screening tool for ongoing intimate partner violence (IPV), the OVAT, and to validate this tool against the present Index of Spouse Abuse (ISA). The design was a prospective survey during randomized 4-hour shifts in an urban emergency department setting. The scale consists of four questions developed based on our previous work. The ISA was compared as the gold standard for detection of present (ongoing) IPV. Of 362 eligible patients presenting during 75 randomized 4-hour shifts, 306 (85%) completed the study. The prevalence of ongoing IPV using the OVAT was 31% (95% CI 26% to 36%). For the ISA, the prevalence was 20% (95% CI 16% to 25%). Compared with the ISA, the sensitivity of the OVAT in detecting ongoing IPV was 86%, specificity 83%, negative predictive value 96%, positive predictive value 56%, with an accuracy of 84%. In conclusion, four brief questions can detect ongoing IPV to aid in identifying the victim.

A five-question Ongoing Abuse Screen (OAS) was developed to evaluate ongoing intimate partner violence. Our hypothesis was that the OAS was more accurate and more likely to reflect ongoing intimate partner violence than the AAS when compared to the Index of Spouse Abuse (ISA). The survey included the ISA, the OAS, and the AAS. During the busiest emergency department hours, a sampling of 856 patients completed all aspects of the survey tool. Comparisons were made between the two scales and the ISA. The accuracy, positive predictive value, and positive likelihood ratio were 84%, 58%, and 6.0 for the OAS and 59%, 33%, and 2.0 for the AAS. The OAS was more accurate, had a better positive predictive value, and was three times more likely to detect victims of ongoing intimate partner violence than the AAS. Because the OAS was still not accurate enough, we developed a new screen, based on the ISA, titled the Ongoing Violence Assessment Tool (OVAT).

Background: The incidence of acute cases of intimate partner violence (IPV) in the Emergency Department (ED) patients is between 2 and 7.2%. Ongoing IPV may be an immediate cause of presentation for medical care, or it may not be readily apparent. Over the last two decades efforts to improve identification of IPV in the ED have been successful. Methods: A medline literature search from 1981-2001 was performed. A review of intimate partner violence from the emergency department provider perspective is performed. A discussion of the screening/detection of intimate partner violence and the barriers to improving detection rates is provided. Results: The review of the current literature shows that IPV is a frequent cause of illness or injury in patients presenting in the ED. Screening programs for intimate partner violence have shown to increase the identification of patients experiencing acute episodes of abuse and seeking treatment. The difficulty has been in sustaining the programs and improving the screening of patients. Patient, provider and systems barriers prevent adequate recognition and management of the problem. Conclusion: Detection of IPV in patients presenting to the ED can be improved by providing educational programs and screening tools to health care providers. Sustaining the screening programs is more difficult and requires a health care system-wide effort. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: KEYWORDS. Intimate partner violence, emergency department, screening, reporting, gender

A topical anesthetic gel containing lidocaine, adrenaline, and tetracaine (LAT) may be as effective as a gel containing tetracaine, adrenaline, and cocaine (TAC) in treating facial and scalp lacerations in children. A study of 95 children ages 5 to 17 who received stitches at a hospital emergency department for facial and scalp lacerations found that the pain of lacerations and stitches was reduced equally well by LAT and TAC. In this study, the tetracaine in TAC was reduced from 1% to 0.5%, with no noticeable difference in pain reduction. LAT was also less expensive and had fewer adverse effects in children. Application to mucous membranes should be avoided, as this may lead to seizures, and in the case of TAC, to seizures and death, in young children. The cost per application of LAT was $3, versus $35 for TAC. Because TAC contains cocaine, a controlled substance, it may need to be kept under close watch while stored in the emergency department. The expense and abuse potential of TAC may indicate that LAT is a better choice for topical anesthesia for lacerations of the face and scalp in children., Study objective. The purpose of the present study is to compare LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) to TAC gel (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) for efficacy, side effects, and costs in children aged 5 to 17 years with facial or scalp lacerations. Design. Randomized, prospective, double-blinded clinical trial. Setting. Inner-city Emergency Department with an Emergency Medicine residency program. Patients or other participants. Children aged 5 to 17 years with linear lacerations of the face or scalp. Intervention. After informed consent was obtained patients had lacerations anesthetized with topical TAC or LAT gel according to a random numbers table. Measurements and main results. A total of 95 patients were included in the statistical analysis with 47 receiving TAC and 48 receiving LAT. Physicians and patients/parents separately rated the overall pain of suturing using a modified multidimensional scale for pain assessment specifically for children. Patients/parents also stated the number of sutures causing pain. The power of the study to determine a ranked sum difference of 15 was 0.8. Multidimensional rating scale results and number and percentage of sutures causing pain were compared using Wilcoxon's rank sum test. According to patients no difference could be detected in percent of sutures causing pain in the LAT versus TAC group (P = .51). Using the multidimensional scale, physicians and patients/parents found LAT statistically the same as TAC in effectiveness (P = .80 for physicians and P = .71 for patients). Cost per application was $3.00 for LAT compared to $35.00 for TAC. Follow-up was accomplished in 85 of 95 participants in the study with no reported complications for either medication. Conclusion. LAT gel worked as well as TAC gel for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT gel appears to be better suited than TAC gel for topical anesthesia in laceration repair in children. Pediatrics 1995,95:255-258; pediatrics, TAC, topical anesthetics, laceration, lidocaine, tetracaine., Optimum characteristics of a local anesthetic for laceration repair in both adults and children are to provide painless application, efficacy, and safety, without distorting tissue planes. In addition, it is [...]