I find myself regularly fascinated by the accuracies (and frequent inaccuracies) of our subjective findings regarding Trauma. Consider how often we hear about details, mechanism, intrusion, extrication time to name a few, and how heavily they guide both pre-hospital and ED workups.  Some interesting studies I have come across are regarding blood loss estimation.  Next time you hear report about blood loss at the scene, contemplate (and feel free to cackle and wisely reference) the following studies: 

The first, published in Prehospital Emergency Care, tested a cohort of EMTs and paramedics on estimating blood volumes spilled on to carpet and vinyl surfaces.  Blood product was poured onto these surfaces and participants estimated total volume demonstrated at six different spill sites.  Mean percent errors of 74% and 56% were calculated for initial estimations!   A similar study published in The Journal of Trauma: Injury, Infection, and Critical Care produced similar results, where only 8% of the 99 providers tested were within 20% of the actual volume, and only 24% were within 50% of actual volume.

Perhaps the more interesting feature of the first study is the post-estimation training that occurred afterwards.  One arm of the cohort returned to the initial scene where actual blood loss was revealed followed by some education on making volume estimates.  The second arm had similar education however this was performed in a classroom using slides instead of returning to the original scene.   Both groups were retested with new scenarios and both demonstrated improvement in mean percent errors to 59% (return to scene) and 45% (slides and classroom), suggesting this may be learn-able skill! 

It turns out we are not much better than our pre-hospital colleagues at blood estimation.  A study from the Western Journal of Emergency Medicine examined a cohort of 56 emergency physicians (mixed residents and attendings).  Participants were tested with 4 different scenarios where specific amounts of blood were poured onto a bedsheet, on gauze, a t-shirt and into a commode.   The mean standard error for all estimates was 116% with a range of 0% to 1233%. Only 8% tested were within 20% of the true value (sound familiar?)!

The next question I arrived at, which you may be thinking yourself, was the fact that these studies do not include scenario or vital signs.  One would expect that would result in more accurate estimates.  Unfortunately, the rabbit hole of my literature search revealed that, even equipped with additional information, both pre-hospital providers and emergency room physicians continued to be poor estimators of blood loss.  A study from The Journal of Trauma tested estimations in set amount of blood amounts (300 mL, 800 mL, and 1500 mL) in a “stable” patient and in an “unstable” patient.  Researchers found that in the stable patient (i.e. normal blood pressure and heart rate) blood loss was underestimated in larger amounts and overestimated in the 300 mL patient.  Remarkably, in the unstable patient, blood loss in both 800 and 1500 mL scenarios were underestimated.  Of the 870 estimates made, 51% were underestimated, 39% were overestimated and only 10% were exact. 

As so nicely asked in the discussion with Frank et al “one has to direct the question if visually estimated blood loss is of any pre-clinical value and worth being mentioned during handover in the emergency unit.“   Perhaps not, but there may be hope with additional training!

 References: 

1. Patton K., Funk DL., McErlean M., Bartfield JM. (2001) Accuracy of estimation of external blood loss by EMS personnel. The Journal of Trauma: Injury, Infection, and Critical Care. 50(5):914-916. 
2. Moscati, R., Billittier, AJ, Marshall, B., Fincher, M., Jehle, D., Braen, GR. (1999) Blood loss estimation by out-of-hospital emergency care providers. Prehospital Emergency Care, Jul-Sep;3(3): 239-42. 
3. Ashburn, J. C., Harrison, T., Ham, J. J., & Strote, J. (2012). Emergency physician estimation of blood loss. The western journal of emergency medicine, 13(4), 376-9. 
4. Frank M., Schmucker U, Stengel D, Fischer L, Lange J, Grossjohann R, Ekkernkamp A, Matthes G. (2010) Proper estimation of blood loss on scene of trauma: tool or tale? The Journal of Trauma. Nov;69(5):1191-5. 

Often when we think of hypoglycemia, our first thought is diabetes. Often times, we are right. Most people that present to the emergency department with hypoglycemia are diabetics and the derangement in their blood glucose is related to medication mismanagement. However, hypoglycemia can occur for other reasons and we should be able to consider a wider differential diagnosis in a patient when an etiology is unclear.

Hypoglycemia is usually considered a blood glucose below 70 mg/dl, however some patients (mainly diabetics) can have symptoms of hypoglycemia above this level because their bodies are used to higher baseline blood glucose levels. This is important to recognize because relative hypoglycemia may be a sign of another pathology and requires treatment and workup depending on the clinical scenario.

We always start out with a thorough history and physical exam. Special attention should be paid to timing of the hypoglycemia related to meals and when medications are taken. In addition, past medical history, medication lists, social history, daily nutrition, and other concurrent symptoms should be obtained to attempt to find the cause.

The differential diagnosis for hypoglycemia in the non-diabetic patient is extensive but includes medications other than those taken by diabetics (fluoroquinolones, beta blockers, pentamidine, valproic acid, and ethanol among others), renal failure, infection/sepsis, starvation, hypothyroidism, pituitary insufficiency, islet and non-islet cell tumors. This is not an exhaustive list and a more complete list can be found on the Life in the Fast Lane website below as well as a mnemonic to help remember this differential.

As far as evaluation of this patient population, it depends on the clinical scenario. If a cause is identified and the patient is safe to have further evaluation by an endocrinologist or primary care physician as an outpatient, then discharge is appropriate. But, if the hypoglycemia is unpredictable or continues to occur despite treatment, the patient requires inpatient admission. Work-up is directed toward the differential diagnosis discussed above with addition of other testing including insulin levels, c-peptide levels, BHOB, and pro-insulin levels which can be undertaken as an outpatient or by the inpatient team. For further information, some resources/ sources for the information above can be found below.

Resources:

https://lifeinthefastlane.com/resources/hypoglycemia-ddx/

https://www.uptodate.com/contents/hypoglycemia-in-adults-without-diabetes-mellitus-diagnostic-approach?search=hypoglycemia&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

There is rarely a shift in the emergency department where we aren’t asked to evaluate an STI-related complaint.  We frequently test for gonorrhea, chlamydia, and trichomoniasis, and we frequently treat for these as well. While the vast majority of these cases are not “emergencies” per se, we recognize how important to public health these diseases can be. Occasionally, I’ve seen people test for hepatitis if there’s an unexplained jaundice, right upper quadrant pain, or GI upset. However, there are two STI’s which we don’t frequently test for in the department, namely HIV and syphilis. Despite their clear dangers to public heath, we don’t test for these often. I’ve heard people give different reasons for this. “We aren’t primary care”, “they can just go to the health department”, or “I don’t want to have to wait on those tests” are some of the most common. We’ve touched on HIV testing at room9er previously, so I’ll limit this post to syphilis and what we can do in the Emergency Department.

Syphilis, which can cause significant morbidity and mortality, has been increasing in prevalence in recent years. In Louisville, there were 73 cases diagnosed in 2014. In 2016, this number increased to 89. There are many different factors that contribute to this, including decreased condom use, availability of new partners on dating apps, and cuts to public health initiatives and clinics. Regardless of the cause, syphilis rates are increasing and we undoubtedly have seen patients who are affected by it during our residency.

Risk factors for syphilis are similar to those of other STI’s. Men who have sex with men, those with multiple sexual partners, patients diagnosed with other STI’s including HIV, pregnant women, patients taking pre-exposure prophylaxis for HIV, and those with partners known or suspected to have syphilis are at increased risk.

So what can we do if a patient comes in with a chief complaint of GU discomfort or STI exposure? Firstly, we need to think about all of the potential diseases, not just the ones we routinely treat such as gonorrhea and chlamydia. Evaluate for risk factors during the history. Look for chancres or other sores during the GU exam, and test and treat as necessary. For those with known exposure, empiric treatment is recommended  by the CDC.  For patients presenting with known exposure, primary, or secondary syphilis,  benzathine penicillin G, 2.4 million units IM is currently recommended. Alternative regimens exist for those who have allergies to penicillin. In other words, testing and treatment are relatively simple and straightforward in the early stages.

If a patient is high-risk, please resist the urge to pass the tasks of testing and treating to their primary doctor. Many of our patients have poor follow up and do not understand the threat this disease poses to public health.