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Background In 2009, Ohio’s Department of Public Safety established statewide geriatric triage criteria to be used by emergency medical services for injured patients age ≥70. Our goal was to evaluate the effect of the criteria on patient outcomes. Design A retrospective cohort study of the Ohio Trauma Registry. Setting All hospitals in Ohio. Participants Patients age ≥70 years in the Ohio Trauma Registry from January 2006 through December 2011, 3 years before and 3 years after criteria adoption. Measurements Primary outcomes were in-hospital mortality and discharge to home. Criteria effects were assessed using chi-square tests, multivariable logistic regression, interrupted time series plots and multivariable segmented regression models. Results We included 34,499 patients. After geriatric criteria adoption, the proportion of patients qualifying for trauma center transport increased from 44% to 58%, but EMS transport rates did not change (44% versus 45%). There was no difference in unadjusted mortality (7.1% versus 6.6%) (p=0.098). In adjusted analyses, subjects with ISS<10 demonstrated decreased mortality (3.0% versus 2.5%) (odds ratio 0.81; 95% CI 0.70–0.95; p=0.011). Discharge to home did increase in the adjusted analysis (odds ratio 1.06, 95% CI 1.01–1.11; p=0.016). There were no time-dependent changes for either outcome. Conclusions Although the proportion of older adults meeting criteria for trauma center transport substantially increased with geriatric triage criteria, there were no increases in trauma center transports. Adoption of statewide geriatric triage guidelines did not improve mortality in more severely injured older adults, but was associated with a small decrease in mortality in mild injury (ISS <10) and with an increase in patients discharged to home. Improving outcomes in injured older adults will require further attention to implementation and use of the geriatric-specific criteria.

preventing resulting morbidities including pneumothorax and pneumonia. Recent literature suggests that many patients with isolated rib fracture may be discharged from the ED. The objective of this study was to determine ED disposition of patients diagnosed with rib fracture in United States (US) and explore select clinical and demographic characteristics. We hypothesized that the proportion of patients with rib fracture admitted from the ED would vary based upon the location and characteristics of the institution providing care.Methods: This was a retrospective, observational cohort study analyzing four years of data (2006)(2007)(2008)(2009) from the Nationwide Emergency Department Sample (NEDS), a part of the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. The NEDS uses a stratified, multi-stage sample that provides national estimates of ED visits each year in the US. The NEDS contains approximately 28 million records per year from over 950 EDs in 28 states. ICD-9-CM diagnosis codes were used to abstract cases of rib fractures. Cases with codes between 807.00 and 807.09 (fracture of rib(s), sternum, larynx, and trachea; fifth digit represents the number of ribs fractured) that were present in the primary diagnosis field were used. The following demographic and clinical variables were examined for visits that resulted in discharge from the ED as well as admission to the hospital: total number of ED visits, age, sex, disposition, hospital region, trauma designation, hospital teaching status and total charges. Weighted estimates and unbiased standard errors were calculated using SAS-Callable SUDAAN.Results: Between 2006 and 2009, there were 844,383 ED visits resulting in a primary diagnosis of rib fracture. Of these visits, 680,574 (80%) resulted in discharge from the ED and 136,727 (16%) resulted in hospital admission. The mean age of the sample was 58 years and 59% of visits were from males. The majority of visits occurred at non-trauma centers (68%) and metropolitan non-teaching hospitals (47%) in the southern region (37%) of the US. A greater percentage of visits that occurred at trauma centers ended in admission (32%) compared to those at non-trauma centers (11%). Additionally, more visits occurred at teaching hospitals (25%) versus non-teaching hospitals (13%). ED disposition for rib fracture visits also varied based upon region. Visits in the western region were most likely to result in admission (19%), whereas those in the southern region were least likely end in admission (14%). Common principal procedures performed were traction, splints and other wound care (22%), chest x-ray (7%) and suture of skin and subcutaneous tissue (4%). The total charge for ED visits was $1,360,388,292 and $1,602,820,036 for visits requiring admission.Conclusions: The disposition of patients diagnosed with rib fracture may be affected by institution trauma designation, teaching status and region. Recent advances in treatment guidelines for rib fracture may contribute to this variability. Whil...

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a 35-year-old woman with a history of congenital ExclusivEly for EM-NEws.coM: dEcEmbEr 4, 2014 numbers of capillary beds must fail before necrotic skin changes manifest. NSTI of the abdomen secondary to strangulated bowel perforation is extremely rare, with almost all occurring post-operatively. (Hernia 2003;7[4]:220.) One case of NSTI on a lower extremity secondary to a perforated inguinal hernia was reported, and a handful of case reports have been reported on perforations causing NSTI, including rectal cancer, diverticulitis, and trauma. (Hernia 2011;15[5]:571; J Plast Reconstr Aesthet Surg 2012;65[12]:1731; J Emerg Med 2008;34[1]:95, Singapore Med J 2009;50[8]:e270.) This is the first case to our knowledge of documented abdominal NSTI secondary to hernia not in a post-operative setting.An NSTI is often misdiagnosed in the early stages, leading to the high mortality rates because of delayed or inadequate treatment. The most common sign includes

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