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Stowell JR, Filler L, Mitchell C, Mahmoudi A, Whiting T, Pastore C, Kunz M, Akhter M. Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department. J Emerg Med 2024; 66:e555-e561. [PMID: 38580514 DOI: 10.1016/j.jemermed.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/11/2023] [Accepted: 01/06/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND Management of acute shoulder dislocation in the emergency department (ED) is common. OBJECTIVE This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED. METHODS The study was a retrospective case-control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts. RESULTS Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2-22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6-84.3%] vs. 68.0% [95% CI 56.8-77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6-97.3%] vs. 84.0% [95% CI 74.4-91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8-47.6%] vs. 29.3% [95% CI 19.9-40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4-31.0%] vs. 45.3% [95% CI 34.4-56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001). CONCLUSIONS The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.
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Affiliation(s)
- Jeffrey R Stowell
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Levi Filler
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Carl Mitchell
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Ashkon Mahmoudi
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Thomas Whiting
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Carl Pastore
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Matthew Kunz
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona
| | - Murtaza Akhter
- Creighton University School of Medicine (Phoenix) Program- Emergency Medicine, Phoenix, Arizona; Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix, Arizona; Department of Emergency Medicine, Valleywise Health, Phoenix, Arizona; Department of Emergency Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania; Department of Emergency Medicine, HCA East Florida, Miami, Florida
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Pringle BD, Hurley GA, McGrath TA, Reed JR, Zapata I, Ross DW. Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians. Wilderness Environ Med 2023; 34:410-419. [PMID: 37451956 DOI: 10.1016/j.wem.2023.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/10/2023] [Accepted: 05/31/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program. METHODS Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting. RESULTS EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation. CONCLUSIONS With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting.
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Affiliation(s)
- Brian D Pringle
- Division of Clinical Medicine and Surgery, Rocky Vista University, Parker, CO.
| | | | - Todd A McGrath
- Wolf Creek Ski Patrol, Pagosa Springs, CO; Department of Emergency Medicine, San Juan Regional Medical Center, Farmington, NM
| | | | - Isain Zapata
- Department of Biomedical Sciences, Rocky Vista University, Parker, CO
| | - David W Ross
- Division of Clinical Medicine and Surgery, Rocky Vista University, Parker, CO
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Mulvey JM, Carson IN, Palmer KA. Closed Reduction of Anterior Shoulder Dislocations Performed by Ski Patrollers in the Alpine Prehospital Environment: A Retrospective Review Demonstrating Efficacy in a Canadian Ski Resort. Wilderness Environ Med 2021; 32:441-449. [PMID: 34635430 DOI: 10.1016/j.wem.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 06/28/2021] [Accepted: 07/14/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Shoulder dislocations are common ski hill injuries. Rapid reduction is known to improve outcomes; however, advanced providers are not always available to provide care to these patients. In 2017, nonmedical ski patrollers at Sunshine Village ski resort in Alberta, Canada, were trained to perform anterior shoulder dislocation (ASD) reductions. Program success was determined by a chart review after the 2020 ski season. METHODS This study retrospectively reviewed data on patients who presented to Sunshine Village ski patrol with a suspected ASD and who met the study inclusion criteria from November 2017 through March 2020. Data were collected from ski patrol electronic patient care records regarding general demographics, reduction technique used, analgesia administration, and reduction success rates. RESULTS Ninety-six cases were available for review after exclusions. Trained nonmedical ski patrollers successfully reduced 82 of these cases, resulting in an overall reduction success rate of 89%. Sixty-three (66%) of these patients had experienced first-time dislocations. Eighty-two (87%) patients were male, with a median age of 25 y. The most used technique was the Cunningham method (75%), and analgesia was administered to 70% of patients. CONCLUSIONS This retrospective study documents the results of a quality assurance review of the treatment of ASD at Sunshine Village ski resort. With a success rate of 89%, the evidence supports the conclusion that nonmedical ski patrollers can successfully perform ASD reductions. We believe training ski patrollers to reduce ASD improved patient care in our austere environment by providing early definitive treatment with a high success rate.
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Affiliation(s)
- Jamin M Mulvey
- Shock Trauma Air Rescue Service, Calgary, Canada; Section of Pediatric Anesthesia, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Ira N Carson
- University of Alberta, School of Medicine, Edmonton, Canada
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Attard Biancardi MA, Jarman RD, Cardona T. Diagnostic accuracy of point-of-care ultrasound (PoCUS) for shoulder dislocations and reductions in the emergency department: a diagnostic randomised control trial (RCT). Emerg Med J 2021; 39:655-661. [PMID: 34544780 DOI: 10.1136/emermed-2020-210947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 09/05/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Following blunt trauma, diagnosis of shoulder dislocation based on physical examination alone is difficult due to possible concurrent proximal humeral fractures. X-rays are therefore used to confirm diagnosis. Results from recent observational studies comparing diagnostic accuracy of point-of-care ultrasound (PoCUS) with X-rays for shoulder dislocation have been encouraging. The aim of this study was to determine whether PoCUS improves diagnostic accuracy when used with physical examination for the diagnosis of shoulder dislocation, proximal humeral fracture and ascertaining successful reduction in the ED. METHODS A prospective, single-centre, open, parallel randomised control study over a 6-month period was used to answer the research question and test the null hypothesis. Consecutive eligible adult patients attending the ED of Mater Dei Hospital in Malta were randomised to either the control (C) (physical examination only) or experimental group (E) (physical examination and a two-point PoCUS scan). The study objectives were to measure diagnostic accuracy for both examinations for detecting shoulder dislocation, any associated proximal humeral fractures and confirming reduction. X-rays were used as reference standard for both groups. RESULTS 1206 patients were enrolled in this study (C n=600, E n=606). 290 dislocations (C n=132 and E n=158), 332 proximal humeral fractures (C n=154 and E n=178) and 278 reductions (C n=130 and E n=148) were analysed. A statistically significant difference (p<0.001) was found between the two groups for diagnostic accuracy in shoulder dislocation (C=65%, likelihood ratio (LR)+=2.03 and LR-=0.35 and E=100%, LR+=∞ and LR-=0), proximal humeral fractures (C=45.7%, LR+=1.23 and LR-=0.52 and E=98.3%, LR+=103.9 and LR-=0.03) and reduction (C=68.7%, E=100%). The null hypothesis for this study was thus rejected. CONCLUSIONS The addition of PoCUS to a physical examination significantly improves diagnostic accuracy for dislocations, proximal humeral fractures and reduction confirmation. TRIAL REGISTRATION NUMBER International Standard Randomised Controlled Trials Number Registry (ISRCTN17048126).
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Affiliation(s)
| | | | - Tania Cardona
- Department for Policy in Health-Health Information and Research, Mater Dei Hospital, Msida, Malta
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Secko MA, Reardon L, Gottlieb M, Morley EJ, Lohse MR, Thode HC, Singer AJ. Musculoskeletal Ultrasonography to Diagnose Dislocated Shoulders: A Prospective Cohort. Ann Emerg Med 2020; 76:119-128. [DOI: 10.1016/j.annemergmed.2020.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/04/2019] [Accepted: 01/02/2020] [Indexed: 10/24/2022]
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The Evolving Role of Ultrasonography in Diagnosing and Managing Shoulder Dislocations. Ann Emerg Med 2020; 76:129-130. [DOI: 10.1016/j.annemergmed.2020.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Indexed: 11/22/2022]
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Gottlieb M, Holladay D, Peksa GD. Point-of-care ultrasound for the diagnosis of shoulder dislocation: A systematic review and meta-analysis. Am J Emerg Med 2019; 37:757-761. [PMID: 30797607 DOI: 10.1016/j.ajem.2019.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/18/2019] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Shoulder dislocations are a common injury causing patients to present to the emergency department. Point-of-care ultrasound (POCUS) has the potential to reduce time, radiation exposure, and healthcare costs among patients presenting with shoulder dislocations. We performed this systematic review and meta-analysis to determine the diagnostic accuracy of ultrasound compared with plain radiography in the assessment of shoulder dislocations. METHODS PubMed, Scopus, CINAHL, LILACS, the Cochrane databases, Google Scholar, and bibliographies of selected articles were assessed for all prospective and randomized control trials evaluating the accuracy of POCUS for identifying shoulder dislocation. Data were dual extracted into a predefined worksheet and quality analysis was performed with the QUADAS-2 tool. Data were summarized and a meta-analysis was performed with subgroup analyses by technique. Diagnostic accuracy of identifying associated fractures was assessed as a secondary outcome. RESULTS Seven studies met our inclusion criteria, comprising 739 assessments with 306 dislocations. Overall, POCUS was 99.1% (95% CI 84.9% to 100%) sensitive and 99.9% (95% CI 88.9% to 100%) specific for the diagnosis of shoulder dislocation with a LR+ of 796.2 (95% CI 8.0 to 79,086.0) and a LR- of 0.01 (95% CI 0 to 0.17). There was no statistically significant difference between techniques. POCUS was also 97.9% (95% CI 10.5% to 100%) sensitive and 99.8% (95% CI 28.0% to 100%) specific for the diagnosis of associated fractures. CONCLUSIONS POCUS is highly sensitive and specific for the identification of shoulder dislocations and reductions, as well as associated fractures. POCUS may be considered as an alternate diagnostic method for the management of shoulder dislocations.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Dallas Holladay
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Selective Prereduction Radiography in Anterior Shoulder Dislocation: The Fresno-Quebec Rule. J Emerg Med 2018; 55:218-225. [DOI: 10.1016/j.jemermed.2018.04.057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/16/2018] [Accepted: 04/27/2018] [Indexed: 01/13/2023]
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9
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Abstract
Shoulder dislocations are a common presentation to the emergency department. Although many cases may be diagnosed by history and clinical examination alone, imaging may help diagnose more challenging cases. Three-view radiographs are important for identifying subtle posterior dislocations, and ultrasonography has been gaining evidence as an alternate diagnostic modality. Intra-articular lidocaine and nerve blocks may improve pain control and reduce the need for procedural sedation. Multiple, evidence-based reduction techniques are described including tips for improving success. Immobilization strategies and follow-up are also discussed.
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Abstract
PURPOSE Shoulder dislocation is a common joint dislocation managed by the emergency physicians in the emergency departments. Pre- and post-reduction radiographic examinations have long been the standard practice to confirm the presence of dislocation and the successful reduction. However, shoulder ultrasonography has recently been proposed as an alternative to the radiographic examination. This study aimed to assess the accuracy of ultrasonography in evaluating proper reduction of the dislocated joint. METHODS This was a prospective observational study. All patients with confirmed anterior shoulder dislocation were examined by both ultrasonography and radiography after the attempt for reduction of the dislocated joint. The examiners were blinded to the result of the other imaging modality. Results of the two methods were then compared. RESULTS Overall, 108 patients with confirmed anterior shoulder dislocation were enrolled in the study. Ninety-one (84.3%) of the patients were males. Mean age of the participants was (30.11 ± 11.41) years. The majority of the patients had a recurrent dislocation. Bedside ultrasonography showed a sensitivity of 53.8% (95% CI: 29.1%-76.8%) and a specificity of 100% (95% CI: 96.1%-100%) in detecting inadequate reductions. The results of ultrasonography had a statistically significant agreement with the results of radiography (Kappa = 0.672, p < 0.001). CONCLUSION The results suggest that the sensitivity of post-reduction ultrasound is not sufficient for it to serve as a substitute for radiography.
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Gottlieb M, Nakitende D, Krass L, Basu A, Christian E, Bailitz J. Frequency of Fractures Identified on Post-Reduction Radiographs After Shoulder Dislocation. West J Emerg Med 2016; 17:35-8. [PMID: 26823928 PMCID: PMC4729416 DOI: 10.5811/westjem.2015.11.28855] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 11/18/2015] [Accepted: 11/30/2015] [Indexed: 11/11/2022] Open
Abstract
Introduction Most emergency physicians routinely obtain shoulder radiographs before and after shoulder dislocations. However, currently there is limited literature demonstrating how frequently new fractures are identified on post-reduction radiographs. The primary objective of this study was to determine the frequency of new, clinically significant fractures identified on post-reduction radiographs with a secondary outcome assessing total new fractures identified. Methods We conducted a retrospective chart review using appropriate International Classification of Diseases, 9th Revision (ICD-9) codes to identify all potential shoulder dislocations that were reduced in a single, urban, academic emergency department (ED) over a five-year period. We excluded cases that required operative reduction, had associated proximal humeral head or shaft fractures, or were missing one or more shoulder radiograph reports. All charts were abstracted separately by two study investigators with disagreements settled by consensus among three investigators. Images from indeterminate cases were reviewed by a radiology attending physician with musculoskeletal expertise. The primary outcome was the percentage of new, clinically significant fractures defined as those altering acute ED management. Secondary outcomes included percentage of new fractures of any type. Results We identified 185 total patients meeting our study criteria. There were no new, clinically significant fractures on post-reduction radiographs. There were 13 (7.0%; 95% CI [3.3%–10.7%]) total new fractures identified, all of which were without clinical significance for acute ED management. Conclusion Post-reduction radiographs do not appear to identify any new, clinically significant fractures. Practitioners should re-consider the use of routine post-reduction radiographs in the ED setting for shoulder dislocations.
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Affiliation(s)
- Michael Gottlieb
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
| | - Damali Nakitende
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
| | - Laurie Krass
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
| | - Anupam Basu
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
| | - Errick Christian
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
| | - John Bailitz
- Cook County Hospital, Department of Emergency Medicine, Chicago, Illinois
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13
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Abstract
Radiographs remain the mainstay for initial imaging of suspected fracture in the emergency setting. Missed fractures potentially have significant negative consequences for patients, referring physicians, and radiologists. Most missed fractures are owing to perceptual errors. In this review, we emphasize knowledge of 3 categories of pitfalls as they pertain to the upper extremity: the common but challenging; the out of mind, out of sight; and those related to satisfaction of search. For specific injuries, emphasis is placed on helpful radiographic signs and important additional radiographic views to obtain.
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Affiliation(s)
- Scott Tyson
- Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-21, Cleveland, OH 44195, USA
| | - Stephen F Hatem
- Department of Radiology, Imaging Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk A-21, Cleveland, OH 44195, USA.
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Shuster M, Abu-Laban RB, Boyd J, Gauthier C, Shepherd L, Turner C. Prospective evaluation of a guideline for the selective elimination of pre-reduction radiographs in clinically obvious anterior shoulder dislocation. CAN J EMERG MED 2015; 4:257-62. [PMID: 17608988 DOI: 10.1017/s148180350000748x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACT:
Objective:
Research has demonstrated that experienced emergency physicians can identify a subgroup of patients with shoulder dislocation for whom pre-reduction radiographs do not alter patient management. Based on that research, a treatment guideline for the selective elimination of pre-reduction radiographs in clinically evident cases of anterior shoulder dislocation was developed and implemented. The primary objective of this study was to prospectively determine whether the treatment guideline safely eliminates unnecessary radiographs.
Methods:
We enrolled a convenience sample of patients who presented to our rural emergency department with possible shoulder dislocation between November 2000 and April 2001. Physicians scored their level of clinical diagnostic certainty on a 10-cm visual analogue scale prior to viewing pre-reduction radiographs (if obtained). Data were collected on clinical scoring and evaluation, compliance with the guideline, and outcomes.
Results:
A total of 63 patients were enrolled, ranging in age from 17 to 79 years (mean = 33); 87.3% were male. Emergency physicians were certain of shoulder dislocation in 59 (93.7%) patients (95% CI, 84.5%–98.2%) and complied with the treatment guideline in 52 patients (82.5%). Most deviations from the treatment guideline involved the elimination of post-reduction radiographs (which the guideline recommends for all patients). The treatment guideline eliminated 56 (88.9%, 95% CI, 78.4%–95.4%) pre-reduction radiographs, as compared to the standard practice of obtaining pre-reduction films for all cases of suspected shoulder dislocation (p < 0.0001)
Conclusions:
Experienced emergency physicians are frequently certain of the diagnosis of anterior shoulder dislocation on clinical grounds alone and can comfortably and safely use this guideline for the selective elimination of pre-reduction radiographs. Compliance with the guideline substantially decreases pre-reduction radiographs. Validation of the guideline in other settings is warranted.
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Affiliation(s)
- Michael Shuster
- Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alberta, Canada
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Lewin MR. Subluxation of clinical skills. Ann Emerg Med 2014; 63:271. [PMID: 24438656 DOI: 10.1016/j.annemergmed.2013.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 08/25/2013] [Accepted: 09/10/2013] [Indexed: 11/26/2022]
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Diagnostic Accuracy of Ultrasonographic Examination in the Management of Shoulder Dislocation in the Emergency Department. Ann Emerg Med 2013; 62:170-5. [DOI: 10.1016/j.annemergmed.2013.01.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Revised: 01/13/2013] [Accepted: 01/28/2013] [Indexed: 11/24/2022]
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Walsh R, Harper H, McGrane O, Kang C. Too good to be true? Our experience with the Cunningham method of dislocated shoulder reduction. Am J Emerg Med 2011; 30:376-7. [PMID: 22100465 DOI: 10.1016/j.ajem.2011.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2011] [Revised: 09/12/2011] [Accepted: 09/13/2011] [Indexed: 11/29/2022] Open
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Do all patients with shoulder dislocations need prereduction x-rays? Am J Emerg Med 2011; 29:609-12. [DOI: 10.1016/j.ajem.2010.01.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/09/2010] [Accepted: 01/11/2010] [Indexed: 11/30/2022] Open
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Shuster M, Abu-Laban RB, Boyd J. The role of radiographs in anterior shoulder dislocation. J Emerg Med 2009; 36:190-191. [PMID: 18835512 DOI: 10.1016/j.jemermed.2007.11.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 11/16/2007] [Indexed: 05/26/2023]
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Abstract
OBJECTIVE We prospectively derived a clinical decision rule to guide pre- and postreduction radiography for emergency department (ED) patients with anterior glenohumeral dislocation. METHODS This prospective cohort derivation study took place at 4 university-affiliated EDs over a 3-year period and enrolled consenting patients with anterior glenohumeral dislocation who were 18 years of age or older. We compared patients with a clinically important fracture-dislocation with those who had an uncomplicated dislocation to provide the clinical decision rule components using recursive partitioning. The final rule involved age, mechanism, prior dislocation and humeral ecchymosis. RESULTS A total of 222 patients were included in the study. Forty (18.0%) had clinically important fracture-dislocation. A clinical decision rule using 4 factors reached a sensitivity of 100% (95% confidence interval [CI] 89.4%-100%), a specificity of 34.2% (95% CI 27.7%-41.2%), a negative predictive value of 99.2% (95% CI 92.8%-99.9%) and a negative likelihood ratio of 0.04 (95% CI 0.002-0.27). Patients younger than 40 years are at high risk for clinically important fracture- dislocation only if the mechanism of injury involves substantial force (i.e., a fall greater than their own height, a sport injury, an assault or a motor vehicle collision). Patients 40 years of age or older are at high risk only in the presence of humeral ecchymosis or after their first dislocation. Projected use of the rule would reduce the absolute number of prereduction radiographs by 27.9% and of postreduction by 81.9%. CONCLUSION The Quebec shoulder dislocation rule for patients with acute anterior glenohumeral dislocation holds promise to reduce unnecessary imaging, pending validation.
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Kahn JH, Mehta SD. The Role of Post-Reduction Radiographs After Shoulder Dislocation. J Emerg Med 2007; 33:169-73. [PMID: 17692769 DOI: 10.1016/j.jemermed.2007.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2006] [Revised: 01/04/2007] [Accepted: 01/12/2007] [Indexed: 11/18/2022]
Abstract
We sought to determine whether post-reduction radiographs add clinically important information to what is seen on pre-reduction X-rays in Emergency Department (ED) patients with anterior shoulder dislocations. In this prospective, observational study, clinicians recorded preliminary pre-reduction and post-reduction X-ray readings on patients with shoulder dislocations. The films were subsequently reviewed by a blinded attending radiologist. Seventy-three patients presented to the ED with shoulder dislocations over an 18-month period; 55 of these patients had pre- and post-reduction X-rays and were included in the study. Eight of these patients had fractures seen on preliminary reading of post-reduction X-rays; one (1.8%, 95% confidence interval [CI] 0-9.7%) of these fractures was not seen on preliminary reading of pre-reduction films. On preliminary reading, all patients' shoulders were relocated on post-reduction X-rays (100%; 95% CI 93.5-100%). Forty of these patients had their X-rays read by a blinded attending radiologist. Sixteen fractures were seen on post-reduction X-rays, of which 6 (15.0%; 95% CI 5.7-29.8%) were not seen on pre-reduction X-rays. All patients (100%; 95% CI 91.2-100%) whose post-reduction films were read by blinded attending radiologists had shoulder relocation confirmed. In conclusion, although the majority (62.5%) of fractures associated with shoulder dislocations are seen on pre-reduction radiographs, more than one-third (37.5%) of fractures may be visible only on post-reduction X-rays. None of the fractures missed on pre-reduction X-rays changed patient management in the ED. There were no persistent shoulder dislocations found on post-reduction films.
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Affiliation(s)
- Joseph H Kahn
- Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Chong M, Karataglis D, Learmonth D. Survey of the management of acute traumatic first-time anterior shoulder dislocation among trauma clinicians in the UK. Ann R Coll Surg Engl 2007; 88:454-8. [PMID: 17002849 PMCID: PMC1964698 DOI: 10.1308/003588406x117115] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this work was to survey how acute traumatic first-time anterior shoulder dislocation (AFSD) is managed among trauma clinicians in UK using a postal questionnaire. PATIENTS AND METHODS A total of 150 questionnaires were sent out to active consultant members of the British Trauma Society in the UK. Questions were laid out in two 'workgroups'. In Workgroup One, an assortment of questions was included regarding choices and methods of analgesia, methods of monitoring used, methods of reduction, and position of immobilisation. In Workgroup Two, three different case scenarios were analysed to look into the 'post-reduction' management. RESULTS The response rate was 60%. Of respondents, 22% have a local protocol for managing AFSD. Almost all respondents recommended pre- and post-reduction X-rays as standard practice. Most respondents favoured systemic analgesia and sedation with airways' monitoring, as opposed to intra-articular anaesthesia (68 versus 9). Eighty-four respondents advocated immobilisation in internal rotation compared to six in external rotation. Only 19% (16 of 84) of respondents would perform an immediate arthroscopic stabilisation in young, fit patients presenting with this type of injury. CONCLUSIONS This survey revealed variations among trauma clinicians in managing AFSD on the 'front-line'. There is a need to address the issue of intra-articular analgesia, immobilisation technique and management of AFSD in the young patient with regards to immediate surgical intervention. We suggest that these issues be revised and clarified, ideally in a randomised, controlled, clinical trial prior to the introduction of a protocol for managing this problem.
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Affiliation(s)
- Mark Chong
- The Royal Orthopaedic Hospital NHS Trust, Birmingham, UK.
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Hendey GW, Chally MK, Stewart VB. Selective radiography in 100 patients with suspected shoulder dislocation. J Emerg Med 2006; 31:23-8. [PMID: 16798149 DOI: 10.1016/j.jemermed.2005.09.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2005] [Accepted: 09/16/2005] [Indexed: 11/18/2022]
Abstract
We sought to prospectively validate an algorithm for selective radiography in the Emergency Department (ED) management of patients with suspected shoulder dislocation. Physicians ordered pre- and post-reduction radiographs based on an algorithm incorporating the mechanism of injury, previous dislocations, and the physician's clinical certainty of joint position. Follow-up consisted of telephone calls and chart review. Of 100 patients, 94 had shoulder dislocation, and 59% were recurrent. Thirty percent had both pre- and post-reduction radiographs, 45% had pre- or post-reduction only, and 25% had no shoulder films, yielding an overall 46% reduction in X-ray utilization. Mean ED times were significantly shorter for patients managed without radiographs. On telephone follow-up (76%) and chart review (100%), we found no missed fractures or persistent dislocations. Use of a clinical decision rule for selective radiography reduced the number of radiographs and time spent in the ED, while missing no fractures or dislocations.
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Affiliation(s)
- Gregory W Hendey
- Department of Emergency Medicine, University of California San Francisco-Fresno, University Medical Center, Fresno, California 93702, USA
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Haapamäki VV, Kiuru MJ, Mustonen AO, Koskinen SK. Multidetector computed tomography in acute joint fractures. Acta Radiol 2005; 46:587-98. [PMID: 16334840 DOI: 10.1080/02841850510021634] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Conventional radiography plays an essential diagnostic role in the primary evaluation of acute joint trauma. In complex fractures, however, computed tomography (CT) is an imaging modality often used second to radiography. As a result of technical breakthroughs in the field, multidetector CT (MDCT) allows faster imaging and better temporal, spatial, and contrast resolution compared with conventional single-slice spiral CT. MDCT with multiplanar reformation is helpful in disclosing fracture patterns, particularly in complex joint fractures, where they reveal occult fractures and show the exact number of fracture components and their degree of displacement.
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Affiliation(s)
- V V Haapamäki
- Department of Radiology, HUS Helsinki Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland.
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25
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Émond M, Le Sage N, Lavoie A, Rochette L. Clinical Factors Predicting Fractures Associated with an Anterior Shoulder Dislocation. Acad Emerg Med 2004. [DOI: 10.1197/j.aem.2004.03.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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te Slaa RL, Wijffels MPJM, Marti RK. Questionnaire reveals variations in the management of acute first time shoulder dislocations in the Netherlands. Eur J Emerg Med 2003; 10:58-61. [PMID: 12637865 DOI: 10.1097/00063110-200303000-00015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
AIM To collect information about the management of patients with acute first time shoulder dislocation by (orthopaedic) surgeons in the accident and emergency departments of Dutch hospitals. DESIGN Questionnaires were sent to 131 (orthopaedic) surgeons of 74 Dutch hospitals. METHOD We enquired whether patients with acute first time shoulder dislocation are managed according to protocols in accident and emergency departments; which radiographs are deemed necessary before and after reduction; which reduction methods are generally performed; and what kind of pain relief or sedatives are generally administered. Furthermore, we enquired into the method and duration of immobilization after reduction. RESULTS The response rate was 73%. Sixty-five per cent of the hospitals are used to managing acute first time shoulder dislocation according to protocols. Making prereduction and postreduction radiographs is standard practice in almost all hospitals. The most favoured methods of reduction are those according to Kocher and Hippocrates. In 85% of cases sedatives are administered before reduction, and in addition to that systemic analgesia is administered in 30%, whereas intra-articular analgesia is preferred in 25% of cases. CONCLUSION Apparently, a protocol for the management of acute first time shoulder dislocation is not standardly available in all hospitals. On the basis of current literature and the results of this questionnaire it may be useful to establish a guideline for diagnostic procedures and the management of acute first time shoulder dislocation in accident and emergency departments.
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Affiliation(s)
- Ron L te Slaa
- Department of Orthopaedics and Traumatology, Reinier de Graaf Hospital, Delft, the Netherlands.
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Perron AD, Ingerski MS, Brady WJ, Erling BF, Ullman EA. Acute complications associated with shoulder dislocation at an academic Emergency Department. J Emerg Med 2003; 24:141-5. [PMID: 12609642 DOI: 10.1016/s0736-4679(02)00717-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Shoulder dislocation is the most frequent dislocation treated in the Emergency Department (ED). Orthopedic literature cites up to a 55% incidence of fracture, vascular or neurologic injury associated with this injury, but these studies suffer from referral bias. No large ED series has been reported. This retrospective chart review was conducted in an academic ED for patients with shoulder dislocation presenting July 1, 1995-June 30, 2000. There were 263 charts identified; 73 were miscoded and 5 were lost, leaving 190 for analysis. Mean age was 34.3 years. Fifty-five patients had at least one fracture (29%), 48 of which (76%) were of the Hill-Sachs type. Despite presence of a fracture, all shoulders underwent successful ED reduction. Sensory nerve deficits were found in 24 (12.6%), which persisted after reduction in 25% of these patients. No vascular injuries were identified. The finding of fracture in 33% of patients with shoulder dislocation is in the range of rates reported in the orthopedic literature (15-55%). The finding that, despite the presence of a fracture, all underwent successful closed reduction is important, as one-third of these patients will have this condition. Neurologic deficits in 12% is significantly lower than the 21-65% reported in the orthopedic literature. Although complications associated with shoulder dislocation were relatively common, they did not significantly affect ED management.
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Affiliation(s)
- Andrew D Perron
- Department of Emergency Medicine, University of Virginia Health System, Charlottesville, Virginia 22908-0699, USA
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Tannebaum RD, Kondabala RK, Stockmal PJ. Postreduction radiographs for anterior shoulder dislocation: a reappraisal. Ann Emerg Med 2001; 37:418-9. [PMID: 11275843 DOI: 10.1067/mem.2001.113955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Hendey GW. Necessity of radiographs in the emergency department management of shoulder dislocations. Ann Emerg Med 2000; 36:108-113. [PMID: 10918101 DOI: 10.1067/mem.2000.108314] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To determine the necessity of radiographs in the emergency department management of patients with suspected shoulder dislocation. METHODS A prospective, observational study was conducted at a university-affiliated, Level I trauma center ED with an emergency medicine residency program. Physicians entered all patients with a suspected shoulder dislocation and reported whether they were certain that the patient's shoulder was dislocated or reduced, before obtaining radiographs. Outcome measures were the assessments of joint position and the radiology reports of prereduction and postreduction films. RESULTS One hundred four patients were enrolled in the study, including 98 with shoulder dislocations, and 191 physician assessments were performed (96 prereduction, 95 postreduction). Twenty-eight patients had recurrent dislocations with an atraumatic mechanism (group 1), and 76 had no prior dislocation or a blunt mechanism of injury (group 2). There were no fractures in group 1 patients; the accuracy of confident assessments was 100% (95% confidence interval 92% to 100%). In group 2, the accuracy of confident assessments was 98% (95% confidence interval 94% to 100%). Incorrect assessments occurred only in patients with fractures. A derived algorithm would have reduced radiographs by 51%. CONCLUSION Physicians are highly accurate in the clinical determination of shoulder dislocation and relocation. Radiographs should be obtained when the physician is uncertain of dislocation or reduction. Prereduction films should be obtained for patients with a blunt traumatic mechanism of injury, and postreduction for those found to have a fracture-dislocation. However, postreduction films add little in patients without fractures, and neither prereduction nor postreduction films are likely to affect the ED management of patients with recurrent dislocation by an atraumatic mechanism. Prospective validation of the derived algorithm is suggested.
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Affiliation(s)
- Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco-Fresno, University Medical Center, Fresno, CA
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Shuster M, Abu-Laban RB, Boyd J. Prereduction radiographs in clinically evident anterior shoulder dislocation. Am J Emerg Med 1999; 17:653-8. [PMID: 10597082 DOI: 10.1016/s0735-6757(99)90152-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The main study objective was to determine if experienced emergency physicians can accurately identify a subgroup of patients with anterior shoulder dislocation for whom prereduction radiographs do not alter patient management. Our prospective study evaluated 97 patients who presented to 2 ski-hill clinics and to our rural emergency department with possible shoulder dislocation between November 1996 and May 1997. Emergency physicians were certain of shoulder dislocation by clinical examination alone in 40 of 59 cases (67.8%) of possible dislocation. All 40 cases were found to have a dislocation (100%; 95% Cl, 91.19% to 100%), and the prereduction radiograph did not affect management of the injury. Prereduction radiographs added 29.6 +/- 12.68 minutes to treatment. We conclude that shoulder dislocation is often readily apparent from history and physical examination. When the experienced emergency physician is certain of the diagnosis of anterior shoulder dislocation, prereduction radiography delays treatment and does not alter management.
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Affiliation(s)
- M Shuster
- Department of Emergency Medicine, Mineral Springs Hospital, Banff, Alberta, Canada
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Kaufman D, Leung J. Evaluation of the patient with extremity trauma: an evidence based approach. Emerg Med Clin North Am 1999; 17:77-95, viii. [PMID: 10101342 DOI: 10.1016/s0733-8627(05)70048-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This article reviews relevant literature to provide evidence based guidelines for the evaluation of patients with extremity trauma in the emergency department. The development of clinical decision rules for extremity trauma in the ankle and knee, and guidelines for obtaining postreduction radiographs of shoulder dislocations and nursemaid's elbows are discussed.
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Affiliation(s)
- D Kaufman
- Division of Emergency Medicine, Northwestern University Medical School, Chicago, Illinois, USA
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