Objectives Acute mesenteric ischemia is an infrequent cause of abdominal pain in emergency department (ED) patients; however, mortality for this condition is high. Rapid diagnosis and surgery are key to survival, but presenting signs are often vague or variable, and there is no pathognomonic laboratory screening test. A systematic review and meta‐analysis of the available literature was performed to determine diagnostic test characteristics of patient symptoms, objective signs, laboratory studies, and diagnostic modalities to help rule in or out the diagnosis of acute mesenteric ischemia in the ED. Methods In concordance with published guidelines for systematic reviews, the medical literature was searched for relevant articles. The Quality Assessment Tool for Diagnostic Accuracy Studies‐2 (QUADAS‐2) for systematic reviews was used to evaluate the overall quality of the trials included. Summary estimates of diagnostic accuracy were computed by using a random‐effects model to combine studies. Those studies without data to fully complete a two‐by‐two table were not included in the meta‐analysis portion of the project. Results The literature search identified 1,149 potentially relevant studies, of which 23 were included in the final analysis. The quality of the diagnostic studies was highly variable. A total of 1,970 patients were included in the combined population of all included studies. The prevalence of acute mesenteric ischemia ranged from 8% to 60%. There was a pooled sensitivity for l‐lactate of 86% (95% confidence interval [CI] = 73% to 94%) and a pooled specificity of 44% (95% CI = 32% to 55%). There was a pooled sensitivity for D‐dimer of 96% (95% CI = 89% to 99%) and a pooled specificity of 40% (95% CI = 33% to 47%). For computed tomography (CT), we found a pooled sensitivity of 94% (95% CI = 90% to 97%) and specificity of 95% (95% CI = 93% to 97%). The positive likelihood ratio (+LR) for a positive CT was 17.5 (95% CI = 5.99 to 51.29), and the negative likelihood ratio (–LR) was 0.09 (95% CI = 0.05 to 0.17). The pooled operative mortality rate for mesenteric ischemia was 47% (95% CI = 40% to 54%). Given these findings, the test threshold of 2.1% (below this pretest probability, do not test further) and a treatment threshold of 74% (above this pretest probability, proceed to surgical management) were calculated. Conclusions The quality of the overall literature base for mesenteric ischemia is varied. Signs, symptoms, and laboratory testing are insufficiently diagnostic for the condition. Only CT angiography had adequate accuracy to establish the diagnosis of acute mesenteric ischemia in lieu of laparotomy.

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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.

Our study was able to demonstrate a survival benefit for the cohort of patients age greater than 55 years of age. Key words: air medical transport; trauma; geriatric.

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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...