The Journal of Emergency Medicine - Articles in Press

Latency of Pulse Oximetry Signal with Use of Digital Probes Associated with Inappropriate Extubation during Prehospital Rapid Sequence Intubation in Head Injury Patients: Case Examples - Corrected Proof

Steve A. Aguilar, Daniel P. Davis — 2012-02-03

Abstract: Background: Endotracheal intubation remains the definitive skill needed for airway management of both medical and surgical patients treated in the prehospital and hospital arenas. Subsequently, rapid sequence intubation (RSI) protocols have been established for various first-line emergency service providers. Because RSI results in the paralysis of skeletal muscles, with a subsequent period of apnea and an increased potential for oxygen desaturation, the accuracy of pulse oximetry (SpO2) data is critical in guiding pre-oxygenation efforts and indicating abandonment of intubation attempts to avoid hypoxic injury. Latency of up to 120 s has been demonstrated in conditions producing peripheral vasoconstriction. The influence of peripheral oximetry on the decision-making process during the establishment of a definitive airway has not, to our knowledge, been previously investigated in the prehospital setting.Objective: To demonstrate how signal latency may manifest itself as a perceived oxygen desaturation with a subsequent premature abortion of a primary RSI attempt or erroneous extubation.Case Examples: We document endotracheal extubation associated with pulse oximetry signal latency during prehospital RSI with the use of digital SpO2 probes. Two case examples are presented that are taken from a retrospective analysis of pre-hospital RSI data recorded by the City of San Diego Emergency Medical Services.Conclusion: To avoid the possibility of mistaking oximetry signal latency for oxygen desaturation during pre-hospital RSI, we propose a conservative approach of aggressive pre-oxygenation to SpO2 values≥94%, and the use of quantitative continuous capnometry for decision-making regarding whether the endotracheal tube is correctly placed. In cases of hypoxemia despite a properly placed tube, focus should be turned to other causes of post intubation hypoxemia.

Cardiac Rupture - Corrected Proof

Betul Gulalp, Ozlem Karagun, Abdullah Tekin, Sibel Benli — 2012-02-03

Abstract: Background: Cardiac rupture is an unusual cause of chest pain and sudden cardiovascular collapse. This diagnosis may be easily forgotten while managing a patient in extremis in the initial minutes of evaluation and resuscitation in the emergency department (ED).Objectives: To report the benefit of immediate bedside cardiac ultrasonography in the diagnosis of cardiac rupture and its influence on emergent intervention in the ED.Case Report: The initial electrocardiogram, performed within 5min of arrival, of a 65-year old man who presented with 20min duration of chest pain, showed a biphasic T wave in V1 and inverted T wave in V2, without ST-segment elevation myocardial infarction. Fifteen minutes later, he lost consciousness and was pulseless without a shockable rhythm on the monitor. Chest compressions were started and the patient was intubated. Echocardiography was performed at the bedside by the emergency physician. Cardiac contractility was grossly decreased in both ventricles and a large amount of pericardial fluid was seen. Two attempts at ultrasound-guided pericardiocentesis yielded only a few milliliters of blood. Interruptions in chest compressions were minimized during pericardiocentesis. Before transport of the patient to the operating room for definitive repair, asystole occurred. On the subsequent echocardiogram, heart contractions were absent and a hematoma was seen in the pericardial space. Resuscitation efforts were stopped. An autopsy was not performed per family request.Conclusions: Typical ultrasonographic findings of cardiac rupture were present in this patient, who presented in extremis with chest pain. Early bedside echocardiography can be helpful in directing the initial care of critically ill patients.

Acute Aortic Regurgitation with Myocardial Infarction: An Important Clue for Aortic Dissection - Corrected Proof

2012-02-03

Abstract: Background: Aortic dissection is an important cause of acute chest pain that should be rapidly diagnosed, as mortality increases with each hour this condition is left untreated. The diagnosis can be challenging, especially if concomitant myocardial infarction is present. Echocardiography is an important tool for the differential diagnosis.Objectives: To stress the importance of recognizing aortic regurgitation for the differentiation of myocardial infarction and aortic dissection.Case Report: An 80-year-old woman was admitted to our hospital with chest pain that was diagnosed as inferior and lateral wall myocardial infarction based on electrocardiographic findings. The diagnosis was reevaluated when aortic regurgitation was detected on echocardiography. Closer inspection of the ascending aorta revealed a dissection flap as the cause of aortic regurgitation.Conclusion: Detection of aortic regurgitation in a patient with myocardial infarction and normal valves should prompt the search for a possible aortic dissection, whether or not the dissection flap can be visualized.

A Physician's Got to Know His (Test's) Limitations - Corrected Proof

Jonathan Edlow — 2012-02-03

“A man’s got to know his limitations.” So ends the 1973 Dirty Harry movie, “Magnum Force.” The same is true of physicians; we have to know our limitations and we also have to know the limitations of our diagnostic tests. Although it is commonly stated that non-contrast brain computed tomography (CT) scan is insensitive to acute posterior circulation infarction, this has not been well studied. In this issue of The Journal of Emergency Medicine, Hwang et al. present data on 67 patients with acute posterior fossa infarction, who first had CT followed by diffusion-weighted magnetic resonance imaging (MRI) within 6h, that revealed an acute ischemic stroke (see Hwang article in this issue).

Recurrent Spontaneous Globe Subluxation: A Case Report and Review of Manual Reduction Techniques - Corrected Proof

Elizabeth W. Kelly, Michael T. Fitch — 2012-02-03

Abstract: Background: Spontaneous globe subluxation is an uncommon problem that develops acutely and can present with significant patient distress from ocular pain and vision loss.Objectives: To present an unusual case of recurrent spontaneous globe subluxation and describe several methods emergency physicians can use to reduce a subluxation.Case Report: We describe a patient with recurrent spontaneous globe subluxation who presented to the Emergency Department with acute ocular pain and vision loss. The subluxation was emergently reduced, resolving the pain and restoring normal vision. Various manual reduction techniques are discussed.Conclusion: There are a number of manual reduction techniques used for treating spontaneous globe subluxation.

Point-of-care Ultrasound Diagnosis of Peripheral Vein Septic Thrombophlebitis in the Emergency Department - Corrected Proof

Srikar Adhikari — 2012-01-30

Intravenous drug users are at high risk for developing skin or subcutaneous abscesses and septic thrombophlebitis of peripheral veins. Septic thrombophlebitis is a condition characterized by inflammation and thrombosis of the vein . The clinical manifestations of peripheral vein septic thrombophlebitis include fever, erythema, tenderness, and purulent drainage at the site of the affected vein . The diagnosis is made based on a combination of clinical manifestations, imaging findings, and culture results. Surgical resection of the involved peripheral venous segment is usually recommended .

Diagnosis and Management of Hereditary Angioedema: An Emergency Medicine Perspective - Corrected Proof

Joseph J. Moellman, Jonathan A. Bernstein — 2012-01-30

Abstract: Background: Hereditary angioedema (HAE) is a rare and often debilitating condition associated with substantial morbidity and mortality in the absence of appropriate intervention. An underlying deficiency in functional C1-inhibitor (C1-INH) protein induces a vulnerability to unchecked activation of the complement, contact, and coagulation/fibrinolytic systems. The clinical consequence is a pattern of recurring attacks of non-pitting, non-pruritic edema, the urgency of which varies by the affected site. Laryngeal edema can escalate rapidly to asphyxiation, and severe cases of abdominal swelling can lead to hypovolemic shock.Objectives: This report reviews the emergency diagnosis and treatment of hereditary angioedema and the impact of recently introduced treatments on treatment in the United States.Discussion: Until recently, emergency physicians in the United States were hindered by the lack of rapidly effective treatment options for HAE attacks. In this article, general clinical and laboratory diagnostic procedures are reviewed against the backdrop of two case studies: one patient presenting with a known history of HAE and one with previously undiagnosed HAE. In many countries outside the United States, plasma-derived C1-INH concentrate has for decades been the first-line treatment for acute attacks. The end of 2009 ushered in a new era in the pharmacologic management of HAE attacks in the United States with the approval of two new treatment options for acute treatment: a plasma-derived C1-INH concentrate and a kallikrein inhibitor.Conclusion: With access to targeted and effective treatments, emergency physicians are now better equipped for successful and rapid intervention in urgent HAE cases.

Identifying False-positive ST-elevation Myocardial Infarction in Emergency Department Patients - Corrected Proof

2012-01-30

Abstract: Background: In a push to treat ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) within 90min of door-to-balloon time, emergency cardiac catheterization laboratory activation protocols bypass routine clinical assessments, raising the possibility of more frequent catheterizations in patients with no culprit coronary lesion.Objective: To determine the incidence, predictors, and prognosis of false-positive STEMI.Methods: We followed a prospective cohort of patients diagnosed with STEMI by usual criteria receiving emergency cardiac catheterization with intention of primary PCI between January 2005 and December 2007 at a tertiary care center. False-positive STEMI was defined as absence of a clear culprit lesion on coronary angiography.Results: Of 489 patients who received emergency cardiac catheterization indicated for STEMI, 54 (11.0%, 95% confidence interval [CI] 8.3–13.8) had no culprit lesion on coronary angiography. Independent predictors of false-positive STEMI were absence of chest pain (odds ratio [OR] 18.2, 95% CI 3.7–90.1), no reciprocal ST-segment changes (OR 11.8, 95% CI 5.14–27.3), fewer than three cardiovascular risk factors (OR 9.79, 95% CI 4.0–23.8), and symptom duration longer than 6h (OR 9.2, 95% CI 3.6–23.7); all p<0.001. Using predictors, we modeled a risk score that achieved 88% (95% CI 81–94%) accuracy in identifying patients with negative coronary angiography. Among the false-positive STEMI patients, 48.1% had other serious diagnoses related to their electrocardiographic findings.Conclusion: When the diagnosis of STEMI is in doubt, clinicians may use predictors to quickly reassess the likelihood of an alternative diagnosis.

A Pain in the Neck: Non-traumatic Adult Retropharyngeal Abscess - Corrected Proof

Christopher K. Schott, Francis L. Counselman, Allison R. Ashe — 2012-01-30

Abstract: Background: We present the case of a 47-year-old man who presented to the Emergency Department (ED) with complaint of left-sided neck pain. He was thought to have a musculoskeletal sprain on his initial visit. However, he returned the following evening with worsening symptoms. On further investigation, he was found to have a non-traumatic retropharyngeal abscess (RPA), a rare infection in the adult patient population.Objectives: This infection has been studied primarily in the pediatric population, and extrapolation of their studies demonstrates the importance of airway stabilization, antibiotic use targeting polymicrobial organisms, and conservative medical management vs. surgical drainage. We aim to summarize this case and review the literature on retropharyngeal abscess.Case Report: This patient presented to the ED with complaints of left-sided neck pain. There was no history of trauma or injury to the affected area. He was evaluated and discharged but returned with a deteriorating clinical picture. On further evaluation, he was found to have a non-traumatic RPA. He was admitted to the Otolaryngology service and managed conservatively with intravenous (IV) antibiotics. His condition resolved and he was subsequently discharged from the hospital.Conclusions: The majority of data on diagnosis and treatment of adult RPA have come from the pediatric population. However, the same essential treatment principles apply: airway stabilization, resuscitation, initiation of IV antibiotics, and consultation with an otolaryngology specialist.

Septic Hip Arthritis: Diagnosis and Arthrocentesis Using Bedside Ultrasound - Corrected Proof

Joseph J. Minardi, Owen M. Lander — 2012-01-30

Abstract: Background: Septic arthritis of the hip is an infrequent disorder that is difficult to diagnose. Traditional methods of obtaining synovial fluid from the hip are not always available in most emergency departments.Objective: To report a case of atypical septic arthritis with the diagnosis and management significantly aided by the use of bedside ultrasound.Case Report: An 18-year-old pregnant woman presented with right hip pain, a normal temperature, and elevated inflammatory markers. She had no risk factors for septic arthritis. The differential diagnosis was broad, but the use of bedside ultrasound assisted in rapidly narrowing the differential, as well as guiding the diagnostic procedure.Conclusions: Bedside ultrasound is a useful tool to evaluate inflammatory disorders of the hip and assists in hip arthrocentesis, a procedure that has not been traditionally performed by most emergency physicians.

Patient Safety in Emergency Medicine - Corrected Proof

Michael J. Ward — 2012-01-30

When I was a Chief Resident at the University of Cincinnati, the single most influential experience I had was educating myself about patient safety. Learning to dissect events that happened in the past to truly understand how and why a decision was made was quite a profound experience. However, this education came with a significant time investment as there was no single resource that could put everything together. I had to find numerous disparate resources, frequently from other industries and medical specialties, then apply this knowledge to my practice of emergency medicine. When I sat down to read Patient Safety in Emergency Medicine, I realized that this was precisely the resource I had hoped for. I wished that this sort of resource had been available to help guide me through my education much as basic textbooks in emergency medicine and ultrasound now do.

Developing an Organized Approach in the Food and Drug Administration to Ban Dangerous Devices that Can Injure the Patient and Health Care Worker - Corrected Proof

2012-01-27

During the past 15 years, the Food and Drug Administration (FDA) and other federal agencies received numerous requests to ban the use of glove powder . It has been suggested that numerous experimental and clinical studies document that powder on medical gloves can enhance foreign body reactions, increase infection, cause peritoneal adhesions that cause intestinal obstruction, and act as a carrier of natural latex allergen that has lead to a latex allergy epidemic in our country.

Ramelteon Ingestions Reported to Texas Poison Centers, 2005–2009 - Corrected Proof

Candice M. Todd, Mathias B. Forrester — 2012-01-27

Abstract: Background: The only data that currently exist on ramelteon (Rozerem®; Takeda Pharmaceuticals North America, Inc., Deerfield, IL) ingestions is from clinical trials. To fill this gap, data on ramelteon ingestions reported to Texas poison centers during 2005–2009 were collected and analyzed.Objectives: The objective of this study was to describe how reported ramelteon ingestions were handled by Texas poison center staff and when known, the patient’s final medical outcome. In cases where the dosage was significant enough to refer the patient to a health care facility, adverse clinical reactions and treatments are also described.Methods: Cases were analyzed for selected demographic and clinical factors. Of 222 total patients, 67.6% were women and 73.9% were over the age of 19 years. Cases were analyzed by motivating factors (e.g., unintentional, intentional), management site, adverse reactions, and final medical outcome.Results: Of the ramelteon ingestions reported to Texas poison centers, 67.6% involved adult women and were suspected attempted suicides; 75% of ramelteon ingestions not involving other substances were managed at a health care facility. However, 88.3% of these ingestions resulted in no significant clinical effect.Conclusion: The management strategies used by Texas poison centers for the 56 cases reported in this study were adequate.

The Spontaneous Rupture of the Renal Fornix Caused by Obstructive Nephropathy - Corrected Proof

2012-01-27

A 62-year-old woman presented to the Emergency Department with right flank pain and decreased urine output for 3 days. She had a history of advanced gastric cancer. The patient had undergone radical total gastrectomy with Roux-en-Y esophagojejunostomy 4 months previously. She had pain and tenderness in the right flank area.

Management of the Post-cardiac Arrest Syndrome - Corrected Proof

Joshua C. Reynolds, Benajmin J. Lawner — 2012-01-27

Abstract: Background: Recent advances in resuscitation science have revolutionized care of the cardiac arrest patient. Dramatic departures from time-honored advanced cardiac life support therapies, such as cardiocerebral resuscitation and bundled post-arrest care, have given rise to a new paradigm of resuscitation practices, which has boosted the rate of neurologically intact survival.Objectives: This article reviews the pathophysiology of the post-cardiac arrest syndrome, the collective pathophysiology after return of spontaneous circulation, and presents management pearls specifically for the emergency physician. This growing area of scientific inquiry must be managed appropriately to sustain improved outcomes.Discussion: The emergency physician must understand this pathophysiology, manage resuscitated patients according to the latest evidence, and coordinate with appropriate inpatient resources.Conclusion: The new approach to cardiac arrest care is predicated on a chain of survival that spans the spectrum of care from the prehospital arena through the emergency, intensive, and inpatient settings. The emergency physician is a crucial link in this chain.

An Incidental Finding? Pneumatosis Intestinalis after Minor Trauma - Corrected Proof

Nathan R. Hoot, Camiron L. Pfennig, Michael N. Johnston, Ian Jones — 2012-01-18

Abstract: Background: Pneumatosis intestinalis (PI) refers to the identification of air within the wall of the gastrointestinal tract. This finding often marks serious underlying pathology, which can be potentially surgical in nature. However, this process may also occur within a benign context, for example, in patients who are chronically immunosuppressed. The prevalence of benign PI may be greater than previously anticipated, because its discovery is facilitated by the increasingly widespread use of computed tomography (CT) scanning.Objectives: We will illustrate how widespread use of CT scanning after trauma leads to incidental findings, some of which are difficult to distinguish from acute pathologic findings. We will also discuss the differential diagnosis for PI and the associated clinical significance.Case Report: A female patient with two autoimmune disorders requiring immunosuppression presented after minor trauma. Her clinical stability and benign examination led us to refrain from ordering a full radiographic evaluation, including an abdominal CT scan. She was safely discharged; however, per CT several days later, the incidental finding was made of PI with free intraperitoneal air. These findings after trauma commonly prompt an exploratory laparotomy. However, given her persistent stability, we attributed this to immunosuppression rather than to recent trauma.Conclusion: The indications for ordering CT scans after minor trauma must be carefully considered, and incidental findings must be interpreted in the context of the overall clinical scenario.

Mobile Phone-assisted Basic Life Support Augmented with a Metronome - Corrected Proof

2012-01-18

Abstract: Background: Basic life support (BLS) performed by lay rescuers is poor. We developed software for mobile phones augmented with a metronome to improve BLS.Study Objectives: To assess BLS in lay rescuers with or without software assistance.Methods: Medically untrained volunteers were randomized to run through a cardiac arrest scenario with (“assisted BLS”) or without (“non–assisted BLS”) the aid of a BLS software program installed on a mobile phone.Results: Sixty-four lay rescuers were enrolled in the “assisted BLS” and 77 in the “non-assisted BLS” group. The “assisted BLS” when compared to the “non-assisted BLS” group, achieved a higher overall score (19.2 ± 7.5 vs. 12.9 ± 5.7 credits; p < 0.001). Moreover, the “assisted BLS” when compared to the “non-assisted” group checked (64% vs. 27%) and protected themselves more often from environmental risks (70% vs. 39%); this group also called more often for help (56% vs. 27%), opened the upper airway (78% vs. 16%), and had more correct chest compressions rates (44% ± 38% vs. 14% ± 28%; all p < 0.001). However, the “assisted BLS” when compared to the “non-assisted BLS” group, was slower in calling the dispatch center (113.6 ± 86.4 vs. 54.1 ± 45.1 s; p < 0.001) and starting chest compressions (165.3 ± 93.3 vs. 87.1 ± 53.2 s; p < 0.001).Conclusions: “Assisted BLS” augmented by a metronome resulted in a higher overall score and a better chest compression rate when compared to “non-assisted BLS.” However, in the “assisted BLS” group, time to call the dispatch center and to start chest compressions was longer. In both groups, lay persons did not ventilate satisfactorily during this cardiac arrest scenario.

Delay in Spinal Cord Injury Diagnosis Due to Sedation: A Case Report - Corrected Proof

Greg Gawor, Kevin Biese, Timothy F. Platts-Mills — 2012-01-16

Abstract: Background: In the United States, the incidence of traumatic spinal cord injury is estimated to be approximately 40 per one million persons per year. The most common causes of traumatic spinal cord injury are motor vehicle collisions, falls, gunshot wounds, and sports accidents.Objective: To report signs, symptoms, clinical presentation, diagnostic modalities, acute management, and treatment of an acute spinal cord injury.Case Report: A case of traumatic cervical spine injury that was not immediately apparent upon presentation is reported. Diagnostic confirmation was possible after obtaining magnetic resonance imaging and after the sedative effects of medications resolved, allowing for a better physical examination.Conclusion: Neurogenic shock should be considered in patients with hypotension of unknown or unclear etiology. A ground-level fall is sufficient to cause traumatic spinal cord injury in elderly patients, and a cervical spine computed tomography scan without clear fracture does not exclude this pathology.

Tension Viscerothorax after Blunt Abdominal Trauma: A Case Report and Review of the Literature - Corrected Proof

Shin Ahn, Won Kim, Chang Hwan Sohn, Dong Woo Seo — 2012-01-16

Abstract: Background: Tension viscerothorax is herniation of abdominal viscera into the thorax. Tension viscerothorax can simulate tension pneumothorax. Immediate decompression with a nasogastric tube is required for hemodynamic stabilization.Objective: A case of tension viscerothorax is reported along with a review of the literature to highlight this rare complication of blunt abdominal trauma, and to emphasize the importance of nasogastric tube decompression in tension viscerothorax.Case Report: A 10-year-old boy with a remote history of trauma related to a motor vehicle crash was brought into the Emergency Department with a 3-day history of vomiting, epigastric pain, and dyspnea. By physical examination and chest X-ray study, tension gastrothorax was diagnosed. Nasogastric tube placement was difficult and delayed, and the patient deteriorated into cardiac arrest, but after successful cardiopulmonary resuscitation and nasogastric tube insertion, the patient was stabilized. Laparotomy was performed and primary repair of a ruptured diaphragm was done. The patient made an uneventful recovery.Conclusion: Acute tension viscerothorax should be considered in the differential diagnosis of tension pneumothorax, and its initial resuscitation should include nasogastric tube insertion for immediate decompression.

Impact of Physician-assisted Triage on Timing of Antibiotic Delivery in Patients Admitted to the Hospital with Community-acquired Pneumonia (CAP) - Corrected Proof

2012-01-16

Abstract: Background: Time to antibiotic delivery in patients with diagnosis of pneumonia is a publicly reported quality measure.Objective: We aim to describe the impact of emergency department (ED) physician-assisted triage (PAT) on The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) pneumonia core quality measures of timing to antibiotic delivery.Methods: Retrospective case series studies of patients admitted to the hospital through the ED with diagnosis of community-acquired pneumonia were identified over a period of 48 months. Patients were included in the study if they met TJC/CMS PN-5 (antibiotic timing) criteria. We compared antibiotic delivery timing before and after implementation of PAT in moderate-acuity patients using Wilcoxon rank sum tests. A linear regression analysis was done to account for age, sex, ED volume, and acuity level.Results: A total of 659 patients were identified: 497 patients and 162 patients enrolled pre- and post-implementation of a PAT, respectively. The median antibiotic delivery times for moderate-acuity patients during open hours of operation of PAT were 180min (pre) and 195min (post), p=0.027; this was unchanged when ED volume, age, sex, and acuity level were accounted for. A total of 43 patients (9%) and 13 patients (8%) failed to receive antibiotics within 6h of ED presentation before and after implementation of PAT, respectively.Conclusion: In this study, implementation of PAT did not result in overall decrease in antibiotic delivery time in patients admitted to the hospital with CAP. We postulate several explanations for this delay in antibiotic delivery time.

Hypermagnesemia in a Constipated Female - Corrected Proof

Yi-Ming Weng, Shou-Yen Chen, Hang-Cheng Chen, Jiun-Hao Yu, Shih-Hao Wang — 2012-01-16

Abstract: Background: Hypermagnesemia is a rare condition that is usually iatrogenic. Magnesium oxide (MgO) ingestion by constipated patients with prolonged colonic retention contributes to hypermagnesemia. Treatment of hypermagnesemia includes discontinuation of the magnesium use, gastrointestinal (GI) decontamination, and removal of magnesium from the serum by dialysis. Calcium acts as an antagonist in hypermagnesemia.Case Report: A 72-year-old woman presented with constipation and MgO ingestion. The patient was brought to our department due to altered mental status and progressive general weakness. Laboratory tests showed a magnesium level of 6.2 mEq/L. Bradycardia and hypotension developed with rebound hypermagnesemia after incomplete dialysis. Abdomen computed tomography showed hyperdense MgO tablets retained in the colon. A magnesium-free laxative was used for GI decontamination. Despite the use of high-dose inotropics and an elevated trigger for transcutaneous pacing, the cardiac performance improved minimally. Although our patient responded to calcium administration with hemodynamic improvement, prolonged hypotension and decreased perfusion led to hypoxic encephalopathy.Conclusion: This report demonstrates that MgO tablets retained in the GI tract without adequate decontamination result in continuous absorption and rebound of hypermagnesemia. This report also addresses the importance of GI decontamination in the treatment of hypermagnesemia.

Cleft Palate Secondary to an Ingested Foreign Body: A Learning Experience - Corrected Proof

Sohit Paul Kanotra, Sonika Kanotra, Jitendra Paul — 2012-01-16

Abstract: Background: Cleft palate has usually been described as a congenital anomaly. Acquired clefting of the palate is rare and is usually due to penetrating trauma.Objective: To report a case of cleft palate developing after ingestion of a coin due to prolonged impaction in the nasopharynx.Case Report: A 4½-year-old child presented with nasal regurgitation and nasal twang of voice. The parents reported a history of ingestion of a coin 2 years prior, which was undetectable on neck and chest X-ray study done at that time. Examination revealed a triangular cleft of soft palate. A diagnosis was made of an acquired cleft palate secondary to prolonged impaction of the coin in the nasopharynx. Under general anesthesia, the palatal defect was repaired in three layers.Conclusion: The case highlights the fact that ingested foreign bodies can get lodged in the nasopharynx and that nasopharynx X-ray study should always be done in cases of a disappearing foreign body in the aerodigestive tract.

Thallium-201 for Cardiac Stress Tests: Residual Radioactivity Worries Patients and Security - Corrected Proof

Matthew J. Geraci, Norman Brown, David Murray — 2012-01-13

Abstract: Background: A 47-year-old man presented to the Emergency Department (ED) in duress and stated he was “highly radioactive.” There were no reports of nuclear disasters, spills, or mishaps in the local area.Objectives: This report discusses the potential for thallium-201 (Tl-201) patients to activate passive radiation alarms days to weeks after nuclear stress tests, even while shielded inside industrial vehicles away from sensors. Characteristics of Tl-201, as used for medical imaging, are described.Case Report: This patient was twice detained by Homeland Security Agents and searched after he activated radiation detectors at a seaport security checkpoint. Security agents deemed him not to be a threat, but they expressed concern regarding his health and level of personal radioactivity. The patient was subsequently barred from his job and sent to the hospital. Tl-201 is a widely used radioisotope for medical imaging. The radioactive half-life of Tl-201 is 73.1h, however, reported periods of extended personal radiation have been seen as far out as 61 days post-administration.Conclusion: This case describes an anxious, but otherwise asymptomatic patient presenting to the ED with detection of low-level personal radiation. Documentation should be provided to and carried by individuals receiving radionuclides for a minimum of five to six half-lives of the longest-lasting isotope provided. Patients receiving Tl-201 should understand the potential for security issues; reducing probable tense moments, confusion, and anxiety to themselves, their employers, security officials, and ED staff.

Inter-rater Reliability of Sonographic Measurements of the Inferior Vena Cava - Corrected Proof

2012-01-13

Abstract: Background: Bedside ultrasound is emerging as a useful tool in the assessment of intravascular volume status by examining measurements of the inferior vena cava (IVC). Many previous studies do not fully describe their scanning protocol.Objectives: The objective of this study was to evaluate which of three commonly reported IVC scanning methods demonstrates the best inter-rater reliability.Methods: Three physicians visualized the IVC in three common views and utilized M-mode to measure the maximal and minimal diameter during quiet respiration. Pairwise correlation coefficients were determined using Pearson product-moment correlation.Results: The most reliable pair of measurements (inspiratory and expiratory) was found to be using the anterior midaxillary line longitudinal view with a Kappa value for both at 0.692.Conclusion: Imaging with the anterior midaxillary longitudinal approach using the liver as an acoustic window provides the best inter-rater reliability when measuring the IVC. Our findings demonstrate that IVC measurements differ based on anatomic location.

Indian and UNITED STATES Paramedic Students: Comparison of Examination Performance for the American Heart Association Advanced Cardiovascular Life Support (ACLS) Training - Corrected Proof

2012-01-13

Abstract: Background: The American Heart Association (AHA) Advanced Cardiovascular Life Support (ACLS) course is taught worldwide. The ACLS course is designed for consistency, regardless of location; to our knowledge, no previous study has compared the cognitive performance of international ACLS students to those in the United States (US).Study Objectives: As international health educational initiatives continue to expand, an assessment of their efficacy is essential. This study assesses the AHA ACLS curriculum in an international setting by comparing performance of a cohort of US and Indian paramedic students.Methods: First-year paramedic students at the Emergency Management and Research Institute, Hyderabad, India, and a cohort of first-year paramedic students from the United States comprised the study population. All study participants had successfully completed the standard 2-day ACLS course, taught in English. Each student was given a 40-question standardized AHA multiple-choice examination. Examination performance was calculated and compared for statistical significance.Results: There were 117 Indian paramedic students and 43 US paramedic students enrolled in the study. The average score was 86% (± 11%) for the Indian students and 87% (± 6%) for the US students. The difference between the average examination scores was not statistically significant in an independent means t-test (p=0.508) and a Wilcoxon test (p=0.242).Conclusion: Indian paramedic students demonstrated excellent ACLS cognitive comprehension and performed at a level equivalent to their US counterparts on an AHA ACLS written examination. Based on the study results, the AHA ACLS course proved effective in an international setting despite being taught in a non-native language.

Adult Intussusception: Presentation, Management, and Outcomes of 148 Patients - Corrected Proof

2012-01-13

Abstract: Background: Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians.Study Objectives: We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period.Methods: A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9th Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors.Results: Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery.Conclusions: Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention.

Hidden Attraction: A Menacing Meal of Magnets and Batteries - Corrected Proof

Julie C. Brown, Karen F. Murray, Patrick J. Javid — 2012-01-13

Abstract: Background: Magnet and button battery ingestions are increasingly common, and can result in significant morbidity. Timely identification of hazardous foreign body ingestions can be difficult in non-verbal and non-disclosing children.Objectives: We aim to present a case that demonstrates some of the challenges around identifying and correctly locating magnets and batteries, and the importance of prompt identification and removal.Case Report: We describe an older child with the covert ingestion of multiple magnets and batteries, with magnets that attracted across the stomach and a loop of jejunum. Mild symptoms and signs resulted in a delayed diagnosis and serious consequences. Radiographs suggested a gastric location of the foreign bodies.Conclusion: Health care workers should consider the possibility of battery or magnet ingestions in children with vomiting and abdominal pain, even when well-appearing. Like esophageal batteries, multiple gastrointestinal magnets and combined magnet-battery ingestions can cause significant morbidity, and prompt identification is important. Providers should ask verbal children for ingestion histories, and consider radiographs when symptoms are atypical or persistent. Like esophageal batteries, gastrointestinal magnet-battery ingestions should be removed promptly to prevent complications. Caregivers should supervise or limit the use of toys that include magnets and batteries.

Implementation of Transvaginal Ultrasound in an Emergency Department Residency Program: An Analysis of Resident Interpretation - Corrected Proof

Casey Z. MacVane, Christine B. Irish, Tania D. Strout, William B. Owens — 2012-01-13

Abstract: Background: Emergency physicians are increasingly performing transvaginal ultrasound (TVUS) to rule out ectopic pregnancy. However, little is known about appropriate educational pathways to train emergency medicine residents in TVUS. StudyObjectives: To evaluate the ability of Emergency Medicine (EM) residents who underwent a training program in TVUS to detect the presence or absence of an intrauterine pregnancy (IUP) in patients of < 13 weeks gestation with vaginal bleeding or abdominal pain, as compared to the final interpretation of each study as determined by the Emergency Department (ED) Director of Ultrasound.Methods: This was a prospective, observational study in a single residency program. Training included a lecture, competency examination, and 10 supervised TVUSs. The EM residents then performed TVUSs with the goal of determining the presence or absence of an IUP without input from an attending physician. Correlation with the ED Director of Ultrasound was assessed for the cohort, and stratified by year of training. Results: There were 22 residents who performed 75 TVUSs over 17 months. Correlation with the ED Director of Ultrasound was 93.3%. Differences in correlation with the ED Director of Ultrasound were noted when compared by year of training: post-graduate year (PGY)-3 (93.3%), PGY-2 (92.1%), and PGY-1 (100%); p < 0.001.Conclusion: Residents were able to perform TVUSs to determine the presence or absence of an IUP in patients in whom the diagnosis of ectopic pregnancy was being considered with a high degree of correlation with the ED Director of Ultrasound after a brief training program. Correlation with the ED director of ultrasound was influenced by year of training.

Oral Thromboprophylaxis in Pelvic Trauma: A Standardized Protocol - Corrected Proof

Daniel Godoy Monzon, Kenneth V. Iserson, Alberto Cid, Jorge A. Vazquez — 2012-01-13

Abstract: Background: Thromboprophylaxis for deep vein thrombosis (DVT) after lower-extremity trauma could include rivaroxaban, an oral medication that does not need laboratory monitoring.Objective: To assess rivaroxaban’s efficacy in preventing DVTs after pelvic trauma compared to its historical incidence.Materials and Methods: All patients admitted with pelvic fractures in a 12-month period followed a standardized thromboprophylaxis protocol: 1) rivaroxaban 10 mg/day within 24 h of injury or upon hemodynamic stability; 2) pre-operative, post-operative, and 30-day extremity ultrasound; 3) ventilation-perfusion scintigraphy for clinical signs of pulmonary embolus; and 4) a 45-, 90-, and 120-day re-evaluation. Rivaroxaban administration ceased the day of surgery and restarted 12 h post-operatively or upon hemodynamic stability, continuing for 30 days. Excluded patients had severe neurological or hepatosplenic injuries, heparin hypersensitivity, or hemodynamic instability.Results: Of 113 patients assessed, 84 patients (66 males), average age 46.6 years (range 19–69 years), were included. They had isolated pelvic trauma (n = 37), associated lower limb injuries (n = 47), average Injury Severity Score 21.4 (range 16–50), and average Glasgow Coma Scale score 13.6 (range 9–15). Patients receiving thromboprophylaxis soon after their fracture (n = 64) had a lower incidence of DVT than those receiving delayed thromboprophylaxis (n = 20) (p = 0.02). One patient (1.2%) died from a pulmonary embolus; 13 had asymptomatic below-the-knee DVTs. Rivaroxaban did not increase intra- or post-operative bleeding in surgical wounds.Conclusions: DVT incidence after pelvic fractures is reduced by administering antithrombotics within 24 h of injury or, if the patient is hemodynamically unstable, 24 h after stabilization. Rivaroxaban is a safe and effective method of providing this thromboprophylaxis.

Intramural Esophageal Hematoma: An Unusual Complication of Endotracheal Intubation - Corrected Proof

Hrvoje Ivekovic, Marina Peklic Ivekovic — 2012-01-13

Intramural esophageal hematoma (IEH) is an uncommon medical condition. IEH is the result of hemorrhage within the esophageal wall, and may occur spontaneously or secondary to trauma . Spontaneous IEH may occur during sudden changes in transmural pressure, such as prolonged episodes of emesis, retching, and coughing . In addition, any type of blood dyscrasias can also lead to the occurrence of IEH . Traumatic causes may be food-induced, or iatrogenic; in particular after endoscopic interventions . Patients with IEH usually present with severe chest pain, dysphagia, odynophagia, and hematemesis .

“Lipid Rescue” for Tricyclic Antidepressant Cardiotoxicity - Corrected Proof

Michael Stephen Blaber, Jamal Nasir Khan, Judith Anne Brebner, Rachel McColm — 2012-01-13

Abstract: Background: Tricyclic antidepressant (TCA) toxicity results predominantly from myocardial sodium-channel blockade. Subsequent ventricular dysrhythmias, myocardial depression, and hypotension cause cardiovascular collapse. Animal studies have demonstrated the effectiveness of intravenous lipid-emulsion in treating TCA cardiotoxicity.Case Report: We report a case of dothiepin (tricyclic antidepressant) overdose causing refractory cardiovascular collapse, which seemed to be successfully reversed with lipid-emulsion therapy (Intralipid®; Fresenius, Cheshire, UK).Conclusions: Lipid emulsions are a potentially novel therapy for reversing cardiotoxicity seen in TCA overdose. Research is required into the role of lipid emulsion in the management of poisoning by oral lipophilic agents.

A Method for the Removal of Tungsten Carbide Rings - Corrected Proof

Keith A. Allen, Marco Rizzo, Annie T. Sadosty — 2012-01-09

Abstract: Background: The removal of metal rings from fingers is a well-described process that often employs a toothed cutting wheel or bolt cutters to sever the ring and allow it to be pried open. However, tungsten carbide (TC) rings are impervious to these traditional ring-cutting devices.Study Objectives: We sought to describe a method for removal of TC rings from cadaveric fingers and characterize potential complications of the technique.Methods: On cadaveric fingers, we placed TC rings and created a snug fit by injecting a fluorescein and saline solution. The rings were removed by a controlled crushing technique using a pair of locking pliers. Fingers were inspected under magnification and using an LED (light-emitting diode) black light, and X-ray studies of each finger were obtained. Injuries were characterized.Results: Six rings were applied and successfully removed from six cadaveric fingers through controlled ring shatter. After ring removal, two fingers demonstrated superficial (< 1 mm deep) lacerations, one of which had residual debris within the wound. No phalangeal fractures were identified.Conclusion: Removal of a TC ring can be performed through controlled crushing using locking pliers. Superficial lacerations and retained debris are potential complications.

A Two-Year Experience of an Integrated Simulation Residency Curriculum - Corrected Proof

Kathleen A. Wittels, James K. Takayesu, Eric S. Nadel — 2012-01-06

Abstract: Background: Human Patient Simulation (HPS) is increasingly used in medical education, but its role in Emergency Medicine (EM) residency education is uncertain.Study Objectives: The objective of this study was to evaluate the perceived effectiveness of HPS when fully integrated into an EM residency didactic curriculum.Methods: The study design was a cross-sectional survey performed in 2006, 2 years after the implementation of an integrated simulation curriculum. Fifty-four residents (postgraduate year [PGY] 1–4) of a 4-year EM residency were surveyed with demographic and curricular questions on the perceived value of simulation relative to other teaching formats. Survey items were rated on a bipolar linear numeric scale of 1 (strongly disagree) to 9 (strongly agree), with 5 being neutral. Data were analyzed using Student t-tests.Results: Forty residents responded to the survey (74% response rate). The perceived effectiveness of HPS was higher for junior residents than senior residents (8.0 vs. 6.2, respectively, p<0.001). There were no differences in perceived effectiveness of lectures (7.8 vs. 7.9, respectively, p=0.1), morbidity and mortality conference (8.5 vs. 8.7, respectively, p=0.3), and trauma conference (8.4 vs. 8.8, respectively, p=0.2) between junior and senior residents. Scores for perceptions of improvement in residency training (knowledge acquisition and clinical decision-making) after the integration of HPS into the curriculum were positive for all residents.Conclusion: Residents’ perceptions of HPS integration into an EM residency curriculum are positive for both improving knowledge acquisition and learning clinical decision-making. HPS was rated as more effective during junior years than senior years, while the perceived efficacy of more traditional educational modalities remained constant throughout residency training.

Do Low-dose Corticosteroids Improve Mortality or Shock Reversal in Patients with Septic Shock? A Systematic Review and Position Statement Prepared for the American Academy of Emergency Medicine - Corrected Proof

Robert Leigh Sherwin, Audwin J. Garcia, Robert Bilkovski — 2012-01-06

Abstract: Background: The management of septic shock has undergone a significant evolution in the past decade. A number of trials have been published to evaluate the efficacy of low-dose corticosteroid administration in patients with septic shock.Methods: The Sepsis Sub-committee of the American Academy of Emergency Medicine Clinical Practice Committee performed an extensive search of the contemporary literature and identified seven relevant trials.Results: Six of the seven trials reported a mortality outcome of patients in septic shock. Analysis of the data revealed that the relative risk (RR) of 28-day all-cause mortality in septic shock patients who received low-dose corticosteroids was 0.92 (95% confidence interval [CI] 0.79–1.07). All seven trials reported data concerning shock reversal or the withdrawal of vasopressors. Pooled results revealed that the RR of shock reversal is 1.17 (95% CI 1.07–1.28), which suggests that there may be significant improvement in shock reversal after corticosteroid administration. It is important to understand that two of the seven studies reviewed were disproportionately represented and accounted for 799 of 1005 patients (80%) considered for this recommendation.Conclusions: The evidence suggests that low-dose corticosteroids may reverse shock faster; however, mortality is not improved for the overall population.

Esophageal Mass: The Importance of Clinical History in Foreign Body Imaging - Corrected Proof

Patricia S. Mangel, Jacob Sedgh, Sohrab Sohrabi, Dhave Setabutr — 2012-01-06

A 48-year-old man with a past history significant for Prader-Willi syndrome, a syndrome characterized by insatiable appetite and decreased mental capacity, was transferred from an outside hospital after presenting with an acute history of sore throat and dysphagia. Given the symptoms of sialorrhea and dysphagia in the background of a mentally impaired patient, there was concern for an obstructing lesion, and imaging was ordered of the neck and chest. Computed tomographic (CT) imaging performed at the outside hospital noted a cavitary lesion of unknown origin in the right retropharyngeal space. The interpretation led to the concern about a possible fungus ball, tumor, or abscess. The outside facility was concerned about the possibility of a large esophageal mass and requested that both Cardiothoracic Surgery and Otolaryngology be contacted.

Complete Heart Block during Potassium Therapy in Thyrotoxic Periodic Paralysis - Corrected Proof

Huei-Fang Wang, Shih-Ching Tsai, Ming-Sung Pan, Chih-Chung Shiao — 2012-01-06

Abstract: Background: Although cardiac dysrhythmia is common in patients with thyrotoxic periodic paralysis (TPP), high-degree atrioventricular (AV) block complicated by cardiogenic shock, even under KCl supplementation, is rarely described.Objectives: To present a case of TPP in a patient who developed complete AV block with severe consequences due to paradoxical hypokalemia during KCl therapy. In addition, the management of acute hypokalemia in TPP is reviewed.Case Report: A 41-year-old Chinese man with TPP presented to the Emergency Department with a 2-day history of paralysis in the extremities. He developed complete AV block with cardiogenic shock and respiratory failure, necessitating ventilatory support when plasma K+ level decreased from 1.7mmol/L to 1.3mmol/L during KCl replacement of 30mmol in 2h. The administration of another 60mmol KCl over 3h achieved a plasma K+ level of 2.1mmol/L, resulting in the resolution of AV block and successful weaning. However, rebound hyperkalemia (K+ 5.6mmol/L) upon recovery was evident and uneventfully corrected.Conclusion: A paradoxical fall in serum K+ concentration with potentially life-threatening complication is still underappreciated in patients with TPP on KCl supplementation. Early recognition and prompt therapy prevent untoward consequences.

Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature - Corrected Proof

Dena A. Reiter, Aaron M. Fischman, Bradley D. Shy — 2012-01-06

Abstract: Background: Ruptured hepatic artery pseudoaneurysm, a type of visceral artery aneurysm, is a rare condition that is life threatening if not diagnosed and treated rapidly in the emergency department (ED). Patients presenting with this condition require aggressive resuscitation. Endovascular embolization is the first-line treatment option.Objectives: We present a case of spontaneously ruptured hepatic artery pseudoaneurysm and provide a review of the current literature on this topic, focusing on appropriate ED management.Case Report: A 41-year-old woman with a history of systemic lupus erythematosus and multiple hepatic bilomas presented to the ED in critical condition with sudden onset of severe abdominal pain and hemodynamic instability. She was found to have a ruptured hepatic artery pseudoaneurysm with marked hemoperitoneum on computed tomography angiography. She was aggressively resuscitated and successfully managed via endovascular embolization.Conclusion: Ruptured hepatic artery pseudoaneurysm is a life-threatening condition that must be rapidly diagnosed and managed in the ED. Visceral artery aneurysm rupture is a diagnosis that should be considered in any patient presenting to the ED with hemodynamic instability and abdominal pain. Definitive management is with endovascular embolization.

Irreducible Fracture of the Proximal Interphalangeal Joint of the Fifth Toe - Corrected Proof

Mischa Veen, Inger B. Schipper — 2012-01-06

Abstract: Background: Interphalangeal joint dislocations of toes are relatively rare and can generally be treated by closed reduction.Objectives: This case presentation intends to emphasize that irreducible lesser toe fractures may represent significant injuries. The minimal external injury and the infrequent presentation of these injuries entail the risk of remaining undiagnosed.Case Report: We present a case of a persistent proximal interphalangeal joint fracture-dislocation of the fifth toe. Open reduction was performed because closed reduction remained unsuccessful as a result of interposition of both the flexor tendon and the volar plate into the fracture line.Conclusions: Even such a minor trauma as a lesser toe injury deserves thorough physical examination, and when indicated on radiological imaging, as significant injuries can easily be overlooked.

A Rare Cause of Poisoning in Childhood: Yellow Phosphorus - Corrected Proof

Mustafa Taskesen, Salih Adıguzel — 2011-12-30

Abstract: Background: Yellow phosphorus poisoning is rare, but when it occurs, it may result in pathological changes in almost all organs of the body, especially the liver, heart, kidney, spleen, and brain, and it has a significant mortality rate.Objectives: This report presents two cases of poisoning by yellow phosphorus in children. Yellow phosphorus ingestion rarely has been reported among the pediatric population.Case Report: This report presents two cases of yellow phosphorus poisoning in children. The patients were admitted with upper abdominal pain, vomiting, lethargy, and respiratory distress. Laboratory testing revealed hepatotoxicity and coagulation disorder. Yellow phosphorus poisoning was treated with conservative therapy in both patients, and one patient died.Conclusion: Yellow phosphorus poisoning is a rare clinical entity and should be considered a dangerous toxic ingestion in children.

Emergency Department Triage: Do Experienced Nurses Agree on Triage Scores? - Corrected Proof

Clémence Dallaire, Julien Poitras, Karine Aubin, André Lavoie, Lynne Moore — 2011-12-30

Abstract: Background: The reproducibility of the Canadian Triage & Acuity Scale (CTAS), designed and introduced in the late 1990s in all Canadian emergency departments (EDs), has been studied mostly using measures of interrater agreement. However, each of these studies shares a common limitation: the nurses had received fresh CTAS training, which is likely to have led to an overestimation of the reproducibility of CTAS.Objectives: This study aims to assess the interrater reliability of the CTAS in current clinical practice, that is, as used by experienced ED nurses without recent certification or recertification.Methods: A prospective sample of 100 patients arriving by ambulance was identified and yielded a set of 100 written scenarios. Five experienced ED nurses reviewed and blindly assigned a CTAS score to each scenario. The agreement among nurses was measured using the Kappa statistic calculated with quadratic weights. Kappa values were generated for each pair of nurses and a global Kappa coefficient was calculated to measure overall agreement.Results: Overall interrater agreement was moderate, with a global Kappa of 0.44 (95% confidence interval 0.40–0.48). However, pairwise, Kappa values were heterogeneous (0.30 to 0.61, p=0.0013).Conclusions: The moderate interrater agreement observed in this study is disappointingly low and suggests that CTAS reliability may be lower than expected, and this warrants further research. Intra-observer reliability of CTAS should be ascertained more extensively among experienced nurses, and a future evaluation should involve several institutions.

Man with Tongue Deviation - Corrected Proof

Josiah Daily, Albert G. Sledge, Henry E. Wang — 2011-12-30

A 60-year-old man presented to the Emergency Department (ED) complaining of a 2-month history of right-sided head, neck, and shoulder pain. He also reported a 3-week history of difficulty speaking and swallowing, the feeling that his tongue had “changed,” as well as a 15-pound weight loss. He reported a history of tobacco use. On neurological physical examination, the patient exhibited normal function of cranial nerves II–XI. However, examination of cranial XII revealed right-sided tongue deviation as well as right hemi-tongue atrophy (). A computed tomography (CT) angiogram of the head and neck was ordered ().

Complication of Acute Myocardial Infarction by Systemic Arterial Embolism in the Era of Multimodality Imaging - Corrected Proof

2011-12-30

A 51-year-old man with a history of smoking was admitted to the hospital with anterolateral myocardial infarction within 3h after the onset of symptoms. Coronary angioplasty of the total occlusion of the proximal left anterior descending artery was performed with implantation of a bare-metal stent. The patient received typical pharmacological treatment, including 300mg of acetylsalicylic acid, 600mg of clopidogrel, 5000 units of unfractionated heparin, and a continuous intravenous infusion of abciximab. Echocardiography, performed the day after admission, showed akinesis within the anterior wall, the interventricular septum, and the apex of the left ventricle (ejection fraction=45%) (A). Contrast echocardiography did not reveal intraventricular thrombus (B, ). On the 6th day of hospitalization, the patient complained of right-hand paresthesia. On physical examination, the hand was pale and cold, with no pulse palpable over the right radial and ulnar arteries. Computed tomography angiography disclosed embolism at the right brachial artery bifurcation (C, ). Two- and three-dimensional echo examinations were performed, revealing large floating and pedunculated left ventricular (LV) thrombus (D, ). The patient underwent simultaneous successful LV thrombectomy and brachial artery embolectomy. The postoperative course was uneventful.

Splenic Abscesses - Corrected Proof

Michael L. Sternberg, Nate P. Lisenbee — 2011-12-30

A 26-year-old woman presented with a 3-week history of increasingly severe left upper quadrant abdominal pain. She had no significant past medical history, but social history was significant for several instances of intravenous drug abuse. Her vital signs were significant for a pulse rate of 140 beats/min and a temperature of 38.6°C (101.5°F). Physical examination was remarkable only for a dull ache to the left upper quadrant and left flank exacerbated with palpation, but without guarding or rebound. Initial laboratory evaluation revealed a white blood cell count of 19,600/μL with 15% band neutrophils. Subsequent immunologic testing showed a highly positive hepatitis C virus antibody, but was otherwise normal.

Referral of Discharged Emergency Department Patients to Primary and Specialty Care Follow-up - Corrected Proof

2011-12-30

Abstract: Background: Emergency department (ED) patients often need urgent primary or specialty care follow-up, but access is particularly difficult for those without insurance.Objective: To characterize follow-up options for uninsured ED patients and to evaluate differences based on ED characteristics.Methods: We mailed a survey to all ED Directors in Colorado, Georgia, Massachusetts, and Oregon (n = 351 EDs). Typical referrals for urgent primary and specialty care follow-up for uninsured patients were classified as: a) private physician or clinic affiliated with the same hospital; b) external public clinic or university hospital; or c) no referral system/policy.Results: Of the 298 (85%) responding EDs, 215 (72%) reported primary care referral to private physicians or clinics at the same hospital and 231 (78%) for specialty care. Twenty (7%) and 27 (9%) EDs had no referral system for primary and specialty care, respectively. Factors associated with typical referral to primary care follow-up at the same hospital were: lower visit volume (85% for EDs with < 1 patient per hour vs. 67% for EDs with ≥ 3 patients per hour); rural area (79% for rural vs. 68% for urban areas), and critical access hospital status (81% critical access vs. 69% non-critical access). Conversely, higher visit volume (87% vs. 58%), urban (81% vs. 72%), and non-critical access hospitals (83% vs. 53%) were more likely to refer for specialty care follow-up at the same hospital.Conclusion: Referral of uninsured ED patients to local follow-up was high for primary and specialty care. Smaller, rural EDs referred within their own hospital more often for primary care but less often for specialty care.

A Case of Rapid Diagnosis of Boerhaave Syndrome by Thoracic Drainage - Corrected Proof

2011-12-26

Abstract: Background: Boerhaave syndrome is a rare and often fatal syndrome. Delayed diagnosis and treatment is closely associated with prolonged morbidity and increased mortality. In general, esophagography is usually chosen as the diagnostic procedure, but it has a relatively high false-negative rate. There are no reports, to our knowledge, regarding the efficacy of thoracic drainage, although it is easier to perform and more immediate than esophagography in the emergency department.Objectives: To report the efficacy of thoracic drainage for rapid diagnosis and treatment of Boerhaave syndrome.Case Report: An 80-year-old woman was admitted with vomiting and sudden onset of postprandial chest pain radiating to the back. Initially, myocardial infarction or aortic dissection was suspected, but was excluded by point-of-care tests and computed tomography (CT) scan, which revealed a left-sided pneumothorax, heterogeneous left pleural effusion, and pneumomediastinum at the lower level of the esophagus. Boerhaave syndrome was suspected and confirmed by thoracic drainage, which drained off bloody fluid and residual food such as broccoli. Emergency thoracotomy was performed within 4 h after onset of symptoms. The patient made an uneventful recovery.Conclusion: Findings in this case indicate that chest pain, left-sided massive effusion on chest radiography, and left-sided massive heterogeneous effusion on CT scan are important for the diagnosis of Boerhaave syndrome. Subsequent thoracic drainage is useful for confirming Boerhaave syndrome, and such a strategy might lead to a good prognosis for patients with this rare but critical disease.

Medical Reconciliation in Patients Discharged from the Emergency Department - Corrected Proof

2011-12-26

Abstract: Background: Medication errors are considered to be a significant cause of morbidity and mortality. For each patient, emergency departments (EDs) are expected to compile a list of medications, reconcile them, and pass them along to the next provider. The electronic medical record provides a method to automatically capture and propagate what may be incorrect information.Objectives: The aim of this study was to compare the medication information that patients ultimately discharged from the ED provide to the ED staff vs. the medication information the patients provide at follow-up, and to classify and quantify the types of discrepancies between the two.Methods: We conducted a retrospective descriptive study of a convenience sample of 36 patients who were discharged from the ED and who reported taking five or more medications. Discrepancies were identified by comparing information collected at the time of the index ED visit with that gleaned from follow-up contact within 7 days of discharge.Results: Of the 36 charts analyzed, 286 medications were provided by patients at the time of their ED visit. Subsequent determination of actual medication use on follow-up found 120 discrepancies, for a discrepancy rate of 42.0% (95% confidence interval [CI] 36.4–47.8%). One or more discrepancies were found on 86.1% of charts (95% CI 74.8–97.4%).Conclusions: Frequent discrepancies are found in the medication information that patients provide in the ED. Requiring the ED to reconcile medication information and to pass it on to the next provider can be a source of treatment errors in the outpatient setting.

Does a Simple Bedside Sonographic Measurement of the Inferior Vena Cava Correlate to Central Venous Pressure? - Corrected Proof

2011-12-26

Abstract: Background: Bedside ultrasound has been suggested as a non-invasive modality to estimate central venous pressure (CVP).Objective: Evaluate a simple bedside ultrasound technique to measure the diameter of the inferior vena cava (IVC) and correlate to simultaneously measured CVP. Secondary comparisons include anatomic location, probe orientation, and phase of respiration.Methods: An unblinded prospective observation study was performed in an emergency department and critical care unit. Subjects were a convenience sample of adult patients with a central line at the superior venocaval-atrial junction. Ultrasound measured transverse and longitudinal diameters of the IVC at the subxiphoid, suprailiac, and mid-abdomen, each measured at end-inspiration and end-expiration. Correlation and regression analysis were used to relate CVP and IVC diameters.Results: There were 72 subjects with a mean age of 67 years (range 21–94 years), 37 (53%) male, enrolled over 9 months. Seven subjects were excluded for tricuspid valvulopathy. Primary diagnoses were: respiratory failure 12 (18%), sepsis 11 (17%), and pancreatitis 3 (5%). There were 28 (43%) patients mechanically ventilated. Adequate measurements were obtainable in 57 (89%) using the subxiphoid, in 44 (68%) using the mid-abdomen, and in 28 (43%) using the suprailiac views. The correlation coefficients were statistically significant at 0.49 (95% confidence interval [CI] 0.26–0.66), 0.51 (95% CI 0.23–0.71), and 0.50 (95% CI 0.14–0.74) for end-inspiratory longitudinal subxiphoid, midpoint, and suprailiac views, respectively. Transverse values were statistically significant at 0.42 (95% CI 0.18–0.61), 0.38 (95% CI 0.09–0.61), and 0.67 (95% CI 0.40–0.84), respectively. End-expiratory measurements gave similar or slightly less significant values.Conclusion: The subxiphoid was the most reliably viewed of the three anatomic locations; however, the suprailiac view produced superior correlations to the CVP. Longitudinal views generally outperformed transverse views. A simple ultrasound measure of the IVC yields weak correlation to the CVP.

The Dilated Vestibular Aqueduct: A Diagnosis Not to Be Missed - Corrected Proof

Moin M. Hoosein, Anil R. Banerjee, Ram Vaidhyanath — 2011-12-26

The most common anomaly associated with childhood deafness is dilated vestibular aqueduct, a bony canal located within the petrous temporal bone. We report a case of a 3-year-old girl who presented to the Emergency Department (ED) of our institution with sudden hearing loss after minor head injury. Imaging findings of this condition are characteristic.

Destructive Cervical Spine Osteoblastoma at C5 in a Young Patient Initially Presenting with Quadriparesis: Case Report and Review of the Literature - Corrected Proof

2011-12-26

Abstract: Background: Osteoblastomas are rare benign bone tumors that are mostly found in the posterior spinal elements; about 20% are located in the cervical spine.Objective: The case of a destructive cervical osteoblastoma at C5 is reported in a 19-year-old man who initially presented with spastic quadriparesis.Case Report: A 19-year-old man was self-referred, reporting symptoms in keeping with a progressive spastic quadriparesis, which had suddenly developed 6 days earlier. Preceding symptoms included mild non-specific neck pain for 3 weeks. The patient was afebrile, and no ambulatory X-ray study had been performed until the time of referral. A cervical spine computed tomography (CT) scan revealed a lytic lesion involving the spinal process and the pedicles of the C5 vertebra. Cervical spine magnetic resonance imaging performed on an inpatient basis revealed a well-circumscribed, destructive lesion of the C5 vertebra, measuring approximately 3 cm. The spinal cord was significantly compressed. The patient underwent open surgical resection of the tumor through a midline posterior approach. Histopathology of the tumor specimen was in keeping with a diagnosis of osteoblastoma.Conclusion: Neuroimaging should be performed with either conventional plain X-ray study, which seems to be sufficient in patients presenting with non-specific symptomatology related to cervical spine damage, or with advanced techniques in the case of patients with persistent neck pain or neurological deficit.

Penetrating Cardiac Injury from a Wooden Knitting Needle - Corrected Proof

Rafael Andrade-Alegre — 2011-12-19

I read with interest the article by Hsia et al. regarding penetrating cardiac injury . As the authors mentioned, advances in technology have provided an increasing number of diagnostic procedures for penetrating cardiac injuries. Today, ultrasound is the initial modality for the evaluation of patients with penetrating precordial wounds because it is accurate, rapid, and non-invasive. Subxiphoid pericardial window was the gold standard for the diagnosis of penetrating cardiac injuries in stable patients up to the mid 1990s . This procedure is rapid, precise, and safe, though invasive. Our experience with the subxiphoid pericardial window was very rewarding, with no false-positive or false-negative results . Similar results have been reported by others . The ratio between hemopericardium and pericardial window was 21%, which means that almost 80% of subxiphoid pericardial windows performed were negative, but in those years this was the most accurate procedure to diagnose or rule out a cardiac injury. We also have moved to the ultrasound as the initial assessment in penetrating trauma cases with risk of cardiac injury. Subxiphoid pericardial window has been left for doubtful ultrasound readings or inexplicable hypotension in multiple trauma patients undergoing emergency abdominal surgery.