The Journal of Emergency Medicine - Articles in Press

Self-Reported Use of Communication Techniques in the Emergency Department - Corrected Proof

Danielle M. McCarthy, Kenzie A. Cameron, D. Mark Courtney, John A. Vozenilek — 2012-05-14

Abstract: Background: Communication is considered a core competency for physicians. However, the Emergency Department setting poses significant and unique communication challenges.Objective: The objective of this study was to explore self-reported use and perceptions of effectiveness and feasibility of communication techniques used by Emergency Physicians for communication with patients.Methods: This cross-sectional study utilized a previously published survey on eight communication techniques. Respondents were asked to quantify their personal use and perceptions of effectiveness and feasibility of each technique. Responses were analyzed for differences based on practice setting (community, academic) and provider role (attending, resident). The survey was administered to a convenience sample recruited at the national meeting of the American College of Emergency Physicians.Results: One hundred and sixty-nine participants were enrolled (70.5% male; 55.8% attending physicians, 44.2% residents; 66.2% practiced in academic settings). Using simple language and speaking slowly to patients were the only techniques identified as being used routinely by a majority of the sample (92.2% and 61.3%, respectively). A majority of the sample ranked seven of the techniques as effective; all techniques were considered feasible in the Emergency Department. No differences were noted across provider role or practice setting.Conclusion: The majority of respondents are not utilizing communication techniques, despite their own beliefs that the techniques are effective and easy to implement in the Emergency Department. Additional research is needed to determine the effectiveness of these techniques and relevant barriers to their use.

A Novel Method for Continuous Environmental Surveillance for Carbon Monoxide Exposure to Protect Emergency Medical Service Providers and Patients - Corrected Proof

Brian L. Risavi, Richard J. Wadas, Cecil Thomas, Douglas F. Kupas — 2012-05-14

Abstract: Background: Carbon monoxide exposure is an important, but frequently undiagnosed, cause for Emergency Medical Services (EMS) response. Its elusive characteristics and non-specific symptoms make detection difficult without monitoring devices. Consequently, both patients and EMS providers are at increased risk of harm from such exposures.Case Series: We report a series of five cases of carbon monoxide encounters, in which carbon monoxide exposure was not suspected, whereby portable (pager-sized) environmental carbon monoxide detectors, that provide continuous surveillance of the ambient air, were utilized. These devices were carried within, or attached to, the first-in medical jump bags, alerting EMS crews to potentially harmful levels of carbon monoxide.Conclusion: This case series highlights the importance of environmental surveillance for carbon monoxide by EMS providers, particularly in such cases where its presence is not suspected. This was, in fact, the case in all the encounters presented herein.

Diagnosis and Endovascular Treatment of an Internal Mammary Artery Injury - Corrected Proof

Lucio Cagini, Jacopo Vannucci, Michele Scialpi, Francesco Puma — 2012-05-14

Internal mammary artery (IMA) disruption after blunt chest trauma is rare. In some instances, it may occur after mild chest trauma with minor external physical findings. However, prompt diagnosis and treatment are necessary, as it can be associated with vascular and parenchymal injuries.

Masked Hypoglycemia in the Presence of Icodextrin for Peritoneal Dialysis - Corrected Proof

Michael M. Khouli — 2012-05-14

Abstract: Background: Handheld glucose meters remain a rapid means of excluding hypoglycemia as a cause of altered mental status in the Emergency Department. However, emergency physicians must be alert for factors that can mask hypoglycemia at the bedside.Case report: An 80-year-old man with diabetes mellitus and end-stage renal disease on peritoneal dialysis presents with altered mental status, hypotension, and a bedside handheld glucose meter reading of 99mg/dL. His mental status failed to improve with treatment of hypotension and the patient was intubated for airway protection. Laboratory-measured serum glucose was 29mg/dL. His mental status improved after glucose administration. It was subsequently determined that the patient used icodextrin (Extraneal®, Baxter Healthcare Corporation, Deerfield, IL) as his peritoneal dialysate. This is partly absorbed into serum and hydrolyzed to oligosaccharides that are falsely detected as glucose by many handheld glucose meters.Conclusion: The peritoneal dialysate icodextrin can produce falsely elevated bedside glucose meter values. As the prevalence of diabetic nephropathy and dialysis increases, emergency physicians must remain vigilant for such cases of unrecognized hypoglycemia.

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective, Observational Study - Corrected Proof

2012-05-14

Abstract: Background: Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.Objectives: Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.Methods: We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.Results: Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.Conclusions: Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.

Severe Chlorate Poisoning Successfully Treated with Methylene Blue - Corrected Proof

Eric Lee, Dong Haur Phua, Beng Leong Lim, Hsin Kai Goh — 2012-05-14

Abstract: Background: Chlorate poisoning as a cause of methemoglobinemia is regarded in current literature to be resistant to treatment by methylene blue due to the oxidizing and denaturing properties of the chlorate anion, and often leads to severe renal and hematological complications with a high mortality rate. Recent case studies suggest practitioners have eschewed the use of methylene blue in such situations.Objectives: This report describes a case of chlorate poisoning presenting as severe methemoglobinemia successfully treated with methylene blue alone, believed to be a first in reported literature.Case Report: A 34-year-old male construction worker presented 4 h after accidental ingestion of an industrial chemical, with giddiness and breathlessness. Physical examination did not reveal any abnormal cardiorespiratory findings, although arterial blood gas analysis and pulse oximetry revealed an “oxygen saturation gap.” Methemoglobin levels were found to be severely elevated at 66.8% 6 h after ingestion, and the patient was promptly treated with methylene blue. Clinical examination and laboratory tests suggested the absence of hemolysis at the time of treatment. The patient was discharged after a brief and uneventful hospital stay. Subsequent tests revealed the chemical ingested to be sodium chlorate.Conclusion: The successful outcome in our case suggests that a window of opportunity as long as 6 h may exist during which treatment of chlorate poisoning with methylene blue may be of clinical value. We postulate that the absence of significant hemolysis and hematological alterations at the time of antidote administration may be a necessary prerequisite for treatment success.

Eyelid Necrotizing Fasciitis: What Were the Early Signs? - Corrected Proof

Anish N. Shah, Alexander C. Day, Vourneen C. Healy, Jane M. Olver — 2012-05-14

Abstract: Background: Necrotizing fasciitis is a rare, life-threatening subcutaneous soft tissue infection that causes massive tissue destruction.Objectives: To illustrate the warning signs of this condition by reporting a rare case of eyelid necrotizing fasciitis.Case Report: A previously healthy 22-year-old man presented with a preseptal eyelid infection that spread rapidly despite prompt treatment with several intravenous antibiotics. He developed the characteristic clinical and radiologic features of necrotizing fasciitis, and required surgical debridement to cure the infection. Histology confirmed the diagnosis.Conclusion: In this article, we suggest the indicators that may enable physicians to think of the development of necrotizing fasciitis in patients with infections of the skin and subcutis.

The Ultrasound-guided “Peripheral IJ”: Internal Jugular Vein Catheterization using a Standard Intravenous Catheter - Corrected Proof

2012-05-14

Abstract: Background: Obtaining vascular access is difficult in certain patients. When routine peripheral venous catheterization is not possible, several alternatives may be considered, each with its own strengths and limitations.Discussion: We describe a novel technique for establishing vascular access in Emergency Department (ED) patients: the placement of a standard catheter-over-needle device into the internal jugular vein using real-time ultrasound guidance. We present a series of patients for whom this procedure was performed after other attempts at vascular access were unsuccessful. In all cases, the procedure was performed quickly and without complications.Conclusion: Although further study of this technique is required, we believe this procedure may be a valuable option for ED patients requiring rapid vascular access.

Orthostatic Hypotension in Children with Acute Febrile Illness - Corrected Proof

Tzippora Shalem, Michael Goldman, Rachel Breitbart, Wendy Baram, Eran Kozer — 2012-05-14

Abstract: Background: Children presenting to the Pediatric Emergency Department (PED) with fever often describe symptoms such as lightheadedness, dizziness, fatigue, and weakness, and may appear pale. They may also present with a chief complaint of syncope. Such symptoms may result from orthostatic hypotension.Objective: To determine whether children with an acute febrile illness have a higher incidence of orthostatic hypotension compared to afebrile children.Methods: A prospective cohort study was conducted at the PED at Assaf Harofeh Medical Center, a university-affiliated hospital in Israel. Eighty children aged 4–18 years were recruited. Thirty-nine had fever (>38°C for 6–48h) and 41 were afebrile. All subjects had their blood pressure measured in the supine position (after 5min of rest) and again after standing for 3min. The main outcome measure was orthostatic hypotension, that is, a reduction of systolic blood pressure of at least 20mm Hg, or a fall in diastolic blood pressure of at least 10mm Hg within 3min of standing.Results: There were no differences between the groups in gender, age, height, or weight. Orthostatic hypotension was found in 10/39 (25.6%) of febrile children and in 2/41 (5%) of afebrile children (p=0.012).Conclusions: The incidence of orthostatic hypotension among febrile children in the PED is high, and may explain common symptoms such as dizziness or syncope. Such patients should be instructed to drink properly and to avoid rapid changes in body posture.

Timely Diagnosis of Perforated Jejunal Diverticulitis by Computed Tomography - Corrected Proof

Vijayanadh Ojili, Mahdieh Parizi, Gowthaman Gunabushanam — 2012-05-14

Abstract: Background: Perforated jejunal diverticulitis is an unusual entity that can present with acute abdominal pain. Due to the non-specific clinical findings, this condition is rarely diagnosed clinically.Case Report: We present the case of a 75-year-old man in whom a perforated jejunal diverticulitis complicated by abscess formation was diagnosed by computed tomography (CT). He underwent a laparotomy with resection of the involved jejunal segment. He had an uneventful recovery and was subsequently discharged.Conclusions: This case report demonstrates the utility of CT in accurately diagnosing this unusual entity that frequently perplexes clinicians.

Oral Magnesium Sulfate Causes Perforation during Bowel Preparation for Fiberoptic Colonoscopy in Patients with Colorectal Cancer - Corrected Proof

Da Ji — 2012-05-10

Oral administration of magnesium sulfate is commonly used for bowel preparation for fiberoptic colonoscopy due to its simplicity, low cost, and effectiveness. However, critical complications such as colon perforation may be missed, and the consequences can be severe. Two cases of colon perforation are reported that resulted from oral magnesium sulfate taken during bowel preparation in colorectal cancer patients.

Cowpox: What do a Dairymaid and a Lab Technician Have in Common? - Corrected Proof

Davut J. Savaser, Vaishal M. Tolia, Peter J. Witucki — 2012-05-07

A 32-year-old woman was working in a local biotechnology laboratory and, while attempting to inoculate a mouse with a cowpox viral strain currently being developed as a live vaccine against smallpox, accidentally self-inoculated the tip of her right index finger with a needle. The patient was seen that day in the Occupational Medicine clinic for the needle-stick and was instructed to return to the Emergency Department (ED) if she developed any symptoms. The patient presented to the ED 5 days later with a lesion on the fingertip (). She was noted to have focal edema as well as red streaking up her left forearm without fevers, chills, or other constitutional symptoms. The Figures depict an isolated cowpox lesion. The cowpox virus used at this biotech laboratory is tagged with fluorescent antibodies, which allowed confirmation of viral inoculation by direct observation under a fluorescent lamp. An Infectious Disease specialist was also consulted, confirming the lesion to be that of cowpox.

The Impact of Two Freestanding Emergency Departments on a Tertiary Care Center - Corrected Proof

Erin L. Simon, Peter L. Griffin, Nicholas J. Jouriles — 2012-05-07

Abstract: Background: Freestanding emergency departments (FEDs) have become increasingly popular as the need for emergency care continues to grow.Objective: To analyze the impact of two FEDs on a local tertiary care center’s patient volume and admission rates.Methods: A retrospective analysis examined monthly volume and admission rates for the main ED and two FEDs located 9.6 and 12 miles away. Main ED census records were divided into three distinct time frames: period A (control) was January 2007 through June 2007. Period B was July 2007 through July 2009 when one FED was open. Period C was August 2009 through June 2010 when both FEDs were open. A two-factor analysis of variance was used to analyze admission rates while adjusting for monthly variation.Results: The mean monthly patient volume for the main ED was 4709 for period A, but dropped significantly (p<0.01) to 4447 for period B, and again dropped significantly (p<0.01) to 4242 during period C. The volume for all facilities increased throughout the study period. A combined monthly volume increase to 5642 occurred in Period B, and increased to 6808 in Period C. The adjusted mean admission rate at the main ED for period A was 0.221, which dropped somewhat, though not significantly (p=0.3505) to 0.213 for period B, and then significantly (p<0.01) to 0.189 for period C.Conclusion: Opening two FEDs decreased the volume and admission rates for the main ED and increased the overall ED volume for the health care system.

A Case of Spontaneous Coronary Artery Dissection: It is Not Always Plaque Rupture - Corrected Proof

Sohil Pothiawala, Fatimah Lateef — 2012-05-07

Abstract: Background: Spontaneous coronary artery dissection (SCAD) is an extremely rare cause of acute coronary syndrome (ACS). Patients may present with a broad spectrum of clinical scenarios, ranging from angina pectoris to myocardial infarction, cardiogenic shock, and sudden death. Standard therapy has not been established; current treatments range from conservative management to percutaneous revascularization or coronary artery bypass surgery.Objective: SCAD greatly mimics ACS, and this diagnosis should be considered when evaluating young patients who present with ACS with or without classical risk factors for coronary artery disease.Case Report: We report a case of a 45-year old man who presented with chest pain typical of ACS. He had no risk factors except for a smoking history of 2.5 pack-years. Once the clinical findings suggested acute inferolateral myocardial infarction, the patient underwent emergent cardiac catheterization, which revealed left anterior descending coronary artery dissection. This in itself is not a common cause of inferolateral ST elevation changes on electrocardiogram.Conclusion: This case highlights the fact that although SCAD is a rare entity, it is increasingly being recognized as a significant cause of ACS. Urgent angiography should be considered if SCAD is suspected, because early diagnosis and appropriate management significantly improve the outcome in these patients.

Single-Dose Etomidate for Intubation in the Trauma Patient - Corrected Proof

Kenny V. Banh, Sidney James, Gregory W. Hendey, Brandy Snowden, Krista Kaups — 2012-05-07

Abstract: Background: Concerns over adrenal suppression caused by a single dose of etomidate for intubation led to limiting its use in trauma patients in 2006.Objective: The purpose of this study was to compare mortality, hypotension, and intensive care unit (ICU) and hospital length of stay (LOS) for trauma patients requiring intubation during periods of liberal vs. limited etomidate use.Methods: A retrospective review of trauma patients requiring emergent intubation who presented between August 2004 and December 2008, before and after we decided to limit the use of etomidate. Data were collected on patient demographics, induction agents used, episodes of hypotension in the first 24h, ICU and total hospital LOS, and survival.Results: Of 1325 trauma patients intubated in the Emergency Department during the study period, 443 occurred during the 23 months before July 2006 (liberal etomidate use) and 882 in the 30 months after July 2006 (limited etomidate use). During the liberal use period, 258/443 (58%) were intubated using etomidate, compared to 205/882 (23%, p<0.0001) during the period of limited use. We found no significant differences in mortality (30% vs. 29%, p=0.70), mean ICU days (8.2 vs. 8.8, p=0.356), or mean hospital LOS (13.8 vs. 14.4 days, p=0.55). Episodes of hypotension were more common in the limited etomidate use group (45% vs. 33%, p<0.0001).Conclusions: A significant reduction in the use of etomidate in trauma patients was not associated with differences in mortality, ICU days, or hospital LOS, but was associated with an increase in episodes of hypotension within 24h of presentation.

Penile Angioedema Developing After 3 Years of ACEI Therapy - Corrected Proof

Daniel G. Miller, Rolla T. Sweis, Theodore S. Toerne — 2012-05-07

Abstract: Background: Angiotensin-converting enzyme inhibitor−related angioedema (ACEI-RA) is a well-described condition, yet isolated genital ACEI-RA is a little-known entity.Objective: A case of isolated genital angioedema is presented with photographic documentation. Possible complications and therapeutic options are discussed.Case Report: A 71-year-old man presented with painless, nonpruritic genital swelling of 4 h duration. Medical history included peptic ulcer disease, hypertension, and benign prostatic hypertrophy. His medications included pantoprazole, hydrochlorothiazide, and lisinopril, which he had been taking for 3 years without any recent change in dosing. He was otherwise asymptomatic and previously had been in good health generally. The physical examination was positive only for diffuse, soft, nonpitting edema isolated to the scrotum and uncircumcised penis. The foreskin was only partially retractable. Urinalysis was normal. All symptoms resolved without complications within 48 h of discontinuing lisinopril and had not recurred at follow-up 4 months later. All cases of ACEI-RA isolated to the genitals that have been reported in the literature resolved without complications.Conclusions: ACEI-RA can present as isolated swelling of the genitals and is a potential cause of genital swelling. Patients who have no evidence of airway compromise, paraphimosis, or urinary retention from complications such as phimosis can be safely discharged with instructions to discontinue the offending agent and to return in case of development of the aforementioned conditions.

Ecthyma Gangrenosum in a 67-Year-Old Man with Chronic Lymphocytic Leukemia - Corrected Proof

Andrew C. Walls, Jason E. Frangos, Eric Goralnick — 2012-05-07

Dermatological presentations are common in patients with malignancy undergoing active treatment, and range from simple dermatoses through complex reactions to disease or cytotoxic therapy to cutaneous manifestations of severe infection. Ecthyma gangrenosum is a necrotizing vasculitis with a characteristic dermatological appearance, and is pathognomonic for severe Gram-negative or fungal infection, most commonly with Pseudomonas aeruginosa. Recognition of these distinctive lesions enables clinical confirmation of severe infection long before culture results are available. We present the case of a man with long-standing chronic lymphocytic leukemia who presented to the Emergency Department (ED) with sepsis syndrome and multiple skin lesions characteristic of ecthyma gangrenosum. He subsequently was confirmed to have Pseudomonas aeruginosa bacteremia.

Comparison of Sitting Face-to-Face Intubation (Two-Person Technique) with Standard Oral-tracheal Intubation in Novices: A Mannequin Study - Corrected Proof

Donna Venezia, Andrew Wackett, Alexander Remedios, Victor Tarsia — 2012-05-07

Abstract: Background: Few studies have evaluated the impact of the upright position on the success of oral-tracheal intubation. Yet, for patients with airway difficulties (i.e, active intraoral bleeding or morbidly obese), the upright position may both benefit the patient and facilitate intubation.Objectives: We compared the success rates of subjects performing standard intubation to a modified version of the sitting face-to-face oral-tracheal intubation technique on a simulation model. We also reviewed the possible advantages and limitations of the sitting face-to-face intubation technique.Methods: Volunteer medical and paramedical students were given instruction, then tested, performing in random order both standard oral-tracheal and two-person sitting face-to-face oral-tracheal intubation on full-bodied mannequins. Observers reviewed video recordings, noting the number of successful intubations and the time to completion of each procedure at 15, 20, and 30 s.Results: All of the sitting face-to-face intubations were successful, 53/53 (100%, 95% confidence interval [CI] 93–100%); whereas of the 53 subjects who performed standard intubation, 48 were successful (91%, 95% CI 80–96%). The difference between successful intubations using the standard vs. sitting face-to-face technique was 9% (95% CI 1.3–9.4%, p=0.025). At times 15 and 20 s, medical student subjects who successfully performed both techniques were less successful at completing the procedure when performing the standard technique as compared to the sitting face-to-face technique (p=0.016). A post-procedural survey found that the majority of subjects preferred the sitting technique.Conclusion: Subjects were significantly more successful at performing and preferred the sitting face-to-face intubation when compared to standard intubation.

Management of the Child after Enema-Reduced Intussusception: Hospital or Home? - Corrected Proof

2012-05-04

Abstract: Background: Standard practice has been to admit children for an observation period after enema-reduced intussusception. However, the utility of such routine practice has not been clearly justified.Study Objectives: The main objective was to determine the rate and timing of recurrent intussusception after successful enema reduction and describe any associated complications.Methods: The study was a retrospective chart review identifying children with enema-reduced intussusception during a 7-year period from 2002 through 2008. Subjects were children ages 0 to 17 years presenting to the Emergency Department (ED) of a tertiary care, free-standing children’s hospital with confirmed and uncomplicated enema-reduced intussusception.Results: During the study period there were 98 children with successful enema reduction of intussusception. There were 10 episodes of recurrence in 7 patients, for an overall recurrence rate of 7.1%. Three patients had two recurrences each, and the remainder had single recurrences. Two patients had early recurrences (<48h) at 3 and 5h, for an early recurrence rate of 2.0%. The late recurrence rate (>48h) was 5.1%. No adverse events were noted in any of the recurrences.Conclusions: Given the low early recurrence rate for enema-reduced intussusception and the minimal risk of adverse outcomes, ED observation for a 6-h period seems to be a safe alternative to inpatient management. These results support previous work and suggest that these patients can be managed on an outpatient basis.

A Rash Case of Hiccups - Corrected Proof

Todd J. Berger — 2012-05-03

Emergency physicians are challenged to maintain an appropriate level of suspicion for acute pathology in the face of a seemingly benign complaint. Many times, a benign symptom represents a harmless ailment. But occasionally, it is a hint to a much more serious problem. Always keep the differential diagnosis broad, asking yourself, “What else can be causing this? What serious, life-threatening things can I be missing?”

The Effect of Gynecologic Algorithm Pathways on Emergency Department Visit Times - Corrected Proof

2012-05-03

Abstract: Background: The use of multidisciplinary algorithmic pathways is one strategy to improve efficiency and quality of care in Emergency Departments (EDs). To this end, in the fall of 2005, we implemented algorithmic pathways for evaluation of ED patients with common gynecologic complaints.Objectives: The goals of this initiative were to improve length of stay as a marker for operational efficiency and to reduce health care disparities by ensuring consistent management regimens for all patients.Methods: A retrospective observational comparison study was performed through a review of consults in the year preceding and the year after implementation of the pathways. The length of stay was calculated based on time of initial triage until discharge. The length of stay from both groups was compared using an unpaired Student's t-test analysis.Results: There was an 85-min decrease in the mean visit time between the pre-intervention group (108 patients, 610min, SD 345.4) and the post-intervention group (105 patients, 525min, SD 251.5), p=0.04.Conclusions: Algorithmic pathways had a positive impact on patient care as measured by the average amount of time our patients spent in the ED. Gynecologic care in the ED was standardized, and length of stay for patients with gynecologic complaints decreased. The implementation of algorithms resulted in more consistent care with earlier initiation of pertinent studies, while facilitating more rapid critical decision-making by providers from both departments. Further analysis is required to examine cost-effectiveness as well as patient safety and provider satisfaction issues.

Amatoxin Poisoning: Case Reports and Review of Current Therapies - Corrected Proof

Jeanine Ward, Kishan Kapadia, Eric Brush, Steven D. Salhanick — 2012-05-03

Abstract: Background: Diagnosis and management of Amanita mushroom poisoning is a challenging problem for physicians across the United States. With 5902 mushroom exposures and two resultant deaths directly linked to Amanita ingestion in 2009, it is difficult for physicians to determine which patients are at risk for lethal toxicity. Identification of amatoxin poisoning can prove to be difficult due to delay in onset of symptoms and difficulty with identification of mushrooms. Consequently, it is difficult for the Emergency Physician to determine proper disposition. Further, treatment options are controversial.Objectives: To review current data to help health care providers effectively identify and treat potentially deadly Amanita mushroom ingestions.Case Reports: We present two cases of Amanita mushroom ingestion in the northeastern United States treated with N-acetylcysteine, high-dose penicillin, cimetidine, and silibinin, a semi-purified fraction of milk thistle-derived silymarin, as part of their treatment regimen. The mushroom species was identified by a consultant as Amanita Ocreata.Conclusions: We present the successful treatment of 2 patients who ingested what we believe to be an Amanita species never before identified in the northeastern United States.

Toxicology and Overdose of Atypical Antipsychotics - Corrected Proof

Alicia B. Minns, Richard F. Clark — 2012-05-03

Abstract: Background: Second-generation antipsychotic medications, or “atypical antipsychotics,” are now first-line therapy in the treatment of schizophrenia and other psychotic disorders, and are additionally being used in a wide array of other psychiatric and non-psychiatric conditions in both adults and children. Overdose is frequently reported to poison control centers.Objectives: We review the toxicology and general management of poisonings involving the atypical antipsychotic medications.Discussion: The most serious toxicity involves the cardiovascular system and the central nervous system. All typical and atypical antipsychotics cause sedation, which is pronounced in overdose. The most common cardiovascular effects that occur after atypical antipsychotic overdose are tachycardia, mild hypotension, and prolongation of the QTc interval. Other clinical syndromes in overdose include neuroleptic malignant syndrome (NMS) and antimuscarinic delirium. Seizures may be observed. No antidotes exist for these poisonings, but they most often do well with supportive care.Conclusion: Antipsychotic overdose produces a gamut of manifestations that affect multiple organ systems. Treatment is primarily supportive. Specific therapies for NMS, hypotension, and seizures are discussed.

Are Oral Medications Effective in the Management of Acute Agitation? - Corrected Proof

Travis I. Gault, Siobhan M. Gray, Gary M. Vilke, Michael P. Wilson — 2012-04-30

Abstract: Background: Current expert guidelines recommend treating agitation with oral medications instead of intramuscular medications if possible. Oral medications are sometimes believed to be inappropriate for the emergency department (ED) as they require patient cooperation and may have a slower onset of action. This review examined published literature for the efficacy of oral agents in agitation.Clinical question: Are oral medications effective at managing acute agitation?Methods: Structured review of PubMed of articles in which the first timepoints of evaluation were<24hours (i.e., the typical timecourse in the ED).Results: 11 articles included for final analysis.Conclusions/Clinical Bottom Line: Treatment with oral medications is as effective as intramuscular medications in rapidly reducing psychotic agitation in the ED. Their use is thought to pose less risk to both patient and ED staff and is less coercive. There is little to no evidence about the use of oral medications for ED patients with extreme agitation.

Massive Human Ingestion of Orpiment (Arsenic Trisulfide) - Corrected Proof

2012-04-30

Abstract: Background: Because the toxicity of arsenic is well known, arsenic-containing compounds have frequently been ingested for suicidal purposes. We report a case of attempted suicide by massive ingestion of arsenic trisulfide, an arsenic mineral of low solubility, which resulted in minimal symptoms.Case Report: An asymptomatic 57-year-old man presented to an Emergency Department 13h after his reported ingestion of approximately 84g of arsenic contained in a mineral specimen of orpiment (arsenic trisulfide) that had been crushed and mixed with an alcoholic beverage and food. His only symptom before presentation was nausea. Physical examination was unremarkable, and diagnostic tests included a normal electrolyte panel, a normal serum lactate, and a normal electrocardiogram. An abdominal radiograph revealed hyper-dense material scattered throughout the large intestine. As per the recommendations of the regional poison center, the patient was managed with whole bowel irrigation with a polyethylene glycol solution, maintenance intravenous hydration, and observation on a telemetry unit. Chelation was not performed. A spot urine specimen collected 12h after admission contained 1490μg of total arsenic per liter (background range<50μg per liter). The patient remained asymptomatic throughout his hospital course. Follow-up studies revealed a diminution in both intra-abdominal radiopacities and urine arsenic concentration. X-ray diffraction analysis of the specimen confirmed its identity as arsenic trisulfide.Conclusions: Our experience demonstrates that massive ingestion of a poorly soluble inorganic arsenic compound can be successfully managed with gastrointestinal decontamination alone without chelation, provided that the patient remains asymptomatic during close clinical monitoring.

Seroprevalence Study Using Oral Rapid HIV Testing in a Large Urban Emergency Department - Corrected Proof

2012-04-30

Abstract: Background: The Centers for Disease Control (CDC) recommends universal human immunodeficiency virus (HIV) testing for patients aged 13–64 years in health care settings where the seroprevalence is>0.1%. Rapid HIV testing has several advantages; however, recent studies have raised concerns about false positives in populations with low seroprevalence.Study Objectives: To determine the seroprevalence of HIV in our Emergency Department (ED) population, understand patient preferences toward rapid testing in the ED, and evaluate the performance of a rapid oral HIV test.Methods: A serosurvey offered oral rapid HIV 1/2 testing (OraQuick ADVANCE, Bethlehem, PA) to a convenience sample of 1348 ED patients beginning August 2008. Subjects declining participation were asked to complete an opt-out survey.Results: 1000 patients were tested. Twelve had positive results (1.2%), including one who had newly diagnosed HIV infection; 988 patients tested negative. Of these, 335 (33.3%) had never been tested; 640 had prior history of a negative HIV test. No false-positive rapid HIV results were detected; 98.7% received the results of their preliminary HIV test, including 100% of those who tested positive. Most subjects who declined testing cited either a recent negative HIV test (160/348) or low perceived risk (65/348). A minority cited a concern regarding their privacy (11/348) or that the test might delay their treatment (7/348).Conclusions: The seroprevalence estimate of 1.2% was above the rate recommended by the CDC for routine universal opt-out testing in our study population. The acceptance rate of rapid HIV testing and the percentage of patients receiving results approximated other recent reports.

Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A Nationwide, Population-based, Observational Study - Corrected Proof

2012-04-30

Abstract: Background: The effect of prehospital use of supraglottic airway devices as an alternative to tracheal intubation on long-term outcomes of patients with out-of-hospital cardiac arrest is unclear.Study Objectives: We compared the neurological outcomes of patients who underwent supraglottic airway device insertion with those who underwent tracheal intubation.Methods: We conducted a nationwide population-based observational study using a national database containing all out-of-hospital cardiac arrest cases in Japan over a 3-year period (2005–2007). The rates of neurologically favorable 1-month survival (primary outcome) and of 1-month survival and return of spontaneous circulation before hospital arrival (secondary outcomes) were examined. Multiple logistic regression analyses were performed to adjust for potential confounders. Advanced airway devices were used in 138,248 of 318,141 patients, including an endotracheal tube (ETT) in 16,054 patients (12%), a laryngeal mask airway (LMA) in 34,125 patients (25%), and an esophageal obturator airway (EOA) in 88,069 patients (63%).Results: The overall rate of neurologically favorable 1-month survival was 1.03% (1426/137,880). The rates of neurologically favorable 1-month survival were 1.14% (183/16,028) in the ETT group, 0.98% (333/34,059) in the LMA group, and 1.04% (910/87,793) in the EOA group. Compared with the ETT group, the rates were significantly lower in the LMA group (adjusted odds ratio 0.77, 95% confidence interval [CI] 0.64–0.94) and EOA group (adjusted odds ratio 0.81, 95% CI 0.68–0.96).Conclusions: Prehospital use of supraglottic airway devices was associated with slightly, but significantly, poorer neurological outcomes compared with tracheal intubation, but neurological outcomes remained poor overall.

Hospitalizations of Older Patients with Human Immunodeficiency Virus in the United States - Corrected Proof

Allison Tadros, Erica Shaver, Stephen M. Davis, Danielle M. Davidov — 2012-04-30

Abstract: Background: Older adults represent a growing percentage of the United States (US) population living with human immunodeficiency virus (HIV). The Emergency Department plays an integral role in the identification and initial evaluation and treatment of patients with HIV.Objective: We sought to estimate the number of hospitalizations of older adults (age≥50 years) with HIV in the United States from 2000 to 2006 and compare features of this population to younger adults with HIV. Clinical and demographic characteristics of the younger cohort (19–49 years) and two older cohorts (ages 50–64 and ≥65 years) were examined and compared.Methods: Data from the Nationwide Inpatient Sample was used to compare the three groups of HIV-positive patients. Comparisons between the most common discharge diagnoses and primary procedures were also made.Results: Older adults with HIV constitute almost one quarter of the hospitalizations of adults with HIV. Older adults with HIV were more likely to be male, have a significantly higher average hospital charge, and have a longer length of stay than younger adults with HIV. Pneumonia and fluid and electrolyte disorders were common diagnoses among all three age cohorts.Conclusions: Older HIV patients were more likely to die during hospitalization compared with younger adults with HIV and older adults without HIV. Admissions for older HIV patients almost doubled during the study period and future studies should examine whether this is due to aging of the current HIV population or new infections.

Emergency Ultrasound of the Gall Bladder: Comparison of a Concentrated Elective Experience vs. Longitudinal Exposure During Residency - Corrected Proof

Timothy B. Jang, Wendy Ruggeri, Amy H. Kaji — 2012-04-30

Abstract: Background: It is unknown how an intensive emergency ultrasound (EUS) experience compares with comparable exposure done over the course of residency training.Objective: Our objective was to compare the accuracy of EUS of the gall bladder done by physicians after a 2-week EUS elective with similarly numbered examinations done by physicians longitudinally over several years of residency training.Methods: This was a secondary analysis of a previously reported prospective study of EUS for biliary disease. The 21st−40th examinations were compared between those who participated in an EUS elective and those who did not. The gold standard was ultrasound done by the Department of Radiology.Results: Mean time to complete 40 EUS examinations for biliary disease was 14 months for those participating in an EUS elective compared with 29 months for those who did not. One hundred and ninety-one examinations (49%) were done by 19 operators who did not participate in an EUS elective and 202 examinations (51%) were done by 23 operators who completed an EUS elective. There was no statistical difference between the two groups with regard to detecting the presence of gall stones, gall bladder wall thickening, pericholecystic free fluid, ductal dilation, or sludge.Conclusions: Physicians who participated in a 2-week, semi-structured EUS elective demonstrated EUS accuracy for biliary disease that was comparable with those who performed the same number of examinations over a longer period of time.

Catatonia in the Emergency Department - Corrected Proof

Katherine E. Kroll, David S. Kroll, Jennifer V. Pope, Carrie D. Tibbles — 2012-04-30

Dr. Katherine Kroll: Today's case is that of a 21-year-old man with a history of psychosis and moderate mental retardation who presented to the Emergency Department (ED) with a chief complaint of “Mental Status Change.” He was transferred on a section 12 from an outside hospital ED to our ED for evaluation of disorganized behavior, self-dialoguing, and odd behavior. On initial evaluation, the patient was able to give only limited history. Although he answered simple and direct questions appropriately, he gave very limited information to open-ended questioning, mainly with one- or two-word answers. He did endorse increased frequency of hearing voices telling him to put a penis in his mouth. He denied depressed mood as well as any suicidal or homicidal ideation. His review of systems was negative, denying any recent fever, chills, vomiting, diarrhea, headache, vision changes, numbness, tingling, weakness, or abnormal gait.

Amphetamine Abuse in Emergency Department Patients Undergoing Psychiatric Evaluation - Corrected Proof

2012-04-27

Abstract: Background: Amphetamine abuse accounts for numerous Emergency Department (ED) visits and is often associated with psychiatric disease, with many patients requiring involuntary psychiatric hold placement. It is a common practice in EDs to obtain a urine drug screen (UDS) as part of the “medical clearance” process for psychiatric patients. However, the prevalence of amphetamine-positive UDS in ED patients with psychiatric disease is unknown, as is the relationship of the UDS test to the final patient disposition.Objectives: The objectives of this study were to determine the prevalence of amphetamine-positive UDS in ED patients undergoing psychiatric evaluation, and whether amphetamine-positive UDS is associated with involuntary psychiatric hold placement.Methods: This was a retrospective study of adult patients seen in a single urban university ED who had a psychiatric evaluation and a UDS over a 1-year period. Eligible patients had results of the UDS, placement of involuntary holds, past psychiatric history, chief complaint, insurance status, and demographic information recorded. Regression analysis was performed, adjusting for the listed covariates, to evaluate the independent association of amphetamine-positive UDS and involuntary psychiatric hold placement.Results: A total of 1207 patients were included for analysis. Amphetamine-positive UDS were found in 14.8% of patients. Multivariate analysis showed no association of a psychiatric hold due to presence of amphetamines on UDS (adjusted odds ratio [OR] 0.76, 95% confidence interval [CI] 0.55–1.05, p=0.1). The only significant factor in placement of an involuntary hold was a past psychiatric history (adjusted OR 1.8, 95% CI 1.2–2.7, p=0.005).Conclusions: The prevalence of amphetamine-positive UDS was high in the study population; however, there was no independent association of amphetamine-positive UDS with involuntary psychiatric hospitalization.

A Novel Use of 2-Octyl-cyanoacrylate: Controlling Post-hemodialysis Site Hemorrhage - Corrected Proof

Tom Perera, Ryan David, Kathy Lin, Siu Fai Li — 2012-04-27

Abstract: Background: A common complication of hemodialysis is bleeding from the dialysis site.Discussion: To demonstrate the use of 2-octyl-cyanoacrylate in controlling venous bleeding associated with hemodialysis access.Conclusion: 2-octyl-cyanoacrylate is effective in stopping venous bleeding from hemodialysis sites.

Front Line Surgery: A Practical Approach - Corrected Proof

Edward J. Otten — 2012-04-23

Hippocrates, in his “On the Surgery” stated that “War is the only proper school of the surgeon” . What was true 2500 years ago may be true today, but it seems a great price to pay for the knowledge obtained. Surgeons have always gone to war, throughout history, and what they learned on the battlefield could often be translated into the civilian sector. Whether it was Ambrose Pare or Jonathan Letterman, with their acute observations, and primitive methods, medicine grew through their efforts. The only similar publication is the Emergency War Surgery handbook published by the Department of Defense in 2004 in its 3rd edition . This text is updated infrequently, and the previous edition in 1988 still contained many of the trauma myths from the Vietnam era. The work reviewed here is a direct-from-the-battlefield, practical approach to trauma care in a Combat Surgical Hospital, Forward Operating Base, or Battalion Aid Station. Many of the authors have 10 years of experience in the Global War on Terrorism (GWOT) in both Iraq and Afghanistan, caring for thousands of wounded soldiers and civilians. The 42 contributors read like a “Who’s Who” of trauma surgeons, not just in the military, but civilian trauma experts who learned their trade in combat: Blackbourne, Eastridge, Holcomb, Rhee, Schreiber, and Shriver.

Pseudocholinesterase Levels Are Not Decreased in Grayanotoxin (Mad Honey) Poisoning in Most Patients - Corrected Proof

2012-04-23

Abstract: Background: The symptoms of mad honey poisoning resemble those of cholinergic toxidromes; however, it is not clear whether they share a common biochemical basis.Objectives: The aim of this study was to investigate a possible resemblance between mad honey poisoning and cholinergic toxidromes.Methods: This is a descriptive study performed prospectively in patients presenting to a University Medical Faculty Emergency Medicine Department emergency service with mad honey poisoning over 1 year, from September 2008 to September 2009. Adult patients with clinical findings suggesting mad honey poisoning (i.e., bradycardia, hypotension, syncope, and vertigo) and with a history of honey consumption were enrolled. Pseudocholinesterase levels in blood samples taken from the mad honey-poisoned patients were analyzed to determine whether these were lower than normal pseudocholinesterase levels for adults (5400–13,200 U/L).Results: The most common symptoms of the 30 patients enrolled in the study were vertigo and nausea. Low blood pressure and bradycardia were the most frequently observed physical examination findings. None of the patients enrolled had a history of disease that might cause low pseudocholinesterase. Mean pseudocholinesterase levels in our patients with mad honey poisoning were 7139.30±2316.41 U/L (min–max: 1785–12,835). Blood pseudocholinesterase levels were within normal limits in 90% of patients and below normal in 10%.Conclusion: A low pseudocholinesterase level was found in 3 (10%) of our 30 patients. These biochemical data do not support the hypothesis that mad honey poisoning should be regarded as cholinergic poisoning.

Emergency Ultrasound Diagnosis of Ovarian Hyperstimulation Syndrome: Case Report - Corrected Proof

Sarah E. Frasure, Joshua S. Rempell, Vicki E. Noble, Andrew S. Liteplo — 2012-04-23

Abstract: Background: Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).Objectives: OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.Case Report: We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.Conclusions: This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.

Bedside Ultrasound for Hip Dislocations - Corrected Proof

Matthew H. Zimny, Bradford L. Walters, Amit Bahl — 2012-04-23

Abstract: Background: Bedside ultrasound in the emergency department is being used with increasing frequency and for an increasing scope of conditions.Objectives: Demonstrate the use of bedside ultrasound as an adjunct for diagnosis of hip dislocation.Case Report: A traumatic anterior hip dislocation was diagnosed with bedside ultrasound after an initial normal plain radiograph.Conclusion: Although the current standard of care for diagnosis of hip dislocation is plain radiographs, this case demonstrates that bedside ultrasound may be used as a diagnostic adjunct in this time-sensitive and potentially catastrophic diagnosis.

Emergency Physicians' and Nurses' Attitudes towards Alcohol-Intoxicated Patients - Corrected Proof

Otis U. Warren, Victoria Sena, Esther Choo, Jason Machan — 2012-04-23

Abstract: Background: Emergency physicians and nurses are frequently dissatisfied professionally when treating alcohol-intoxicated patients, and have negative attitudes towards this patient population and alcohol rehabilitation.Study Objectives: The goal of this study is to examine differences in attitudes between emergency physicians and nurses towards alcohol-intoxicated patients.Methods: This single-site survey study evaluated emergency physicians' and nurses': 1) attitudes of personal professional satisfaction and dissatisfaction when caring for intoxicated patients; 2) attitudes towards the difficulty in caring for alcohol-intoxicated patients; 3) attitudes towards respect of the alcohol-intoxicated patient; 4) attitudes towards the adequacy of training in caring for intoxicated patients; 5) attitudes towards rehabilitation and counseling of alcohol-intoxicated patients.Results: Physicians were less satisfied and more dissatisfied than nurses when caring for alcohol-intoxicated patients. Physicians found treating alcohol-intoxicated patients more difficult than nurses did. Physicians were more likely to agree that alcohol-intoxicated patients should be treated with respect. Physicians felt more adequately trained than nurses in caring for alcohol-intoxicated patients. Nurses were more likely to believe that alcohol-related rehabilitation is ineffective compared with physicians. Both nurses and physicians refer alcohol-intoxicated patients to rehabilitation to a similar extent.Conclusions: Emergency physicians and nurses have similar attitudes but significant differences in the extent of these attitudes towards the care of the alcohol-intoxicated patient.

Uncommon Clavicle Fracture that Could be Easily Overlooked - Corrected Proof

Yu-Jang Su, Shih-Fen Tseng, Yen-Chun Lai — 2012-04-23

A 33-year-old man presented to the Emergency Department complaining of right upper chest and right shoulder pain after a motor vehicle accident. The initial physical examination showed neither deformity nor crepitus over the upper chest wall. Chest X-ray study looked unremarkable in the bony structures (). The patient was given ketorolac 30 mg intramuscularly for the relief of pain and an ice pack was applied to the painful site.

Prostatitis or Prostatic Abscess - Corrected Proof

Wilbur R. Dattilo, Joseph Shiber — 2012-04-23

A 65-year-old Hispanic man with a history of type 2 diabetes mellitus, coronary artery disease, and peripheral vascular disease presented to the Emergency Department (ED) complaining of fever and constipation with lower back and rectal pain. During the previous 6 weeks, he had experienced progressive urinary retention and had presented to his primary care provider (PCP) and to the ED several times for dysuria and lower back pain.

Severe Pasteurella Multocida Infection after a Dog Bite - Corrected Proof

2012-04-23

Bite infections can contain a mixture of anaerobes and aerobes from the patient’s skin and the animal’s oral cavity, including species of Pasteurella, Streptococcus, Fusobacterium, and Capnocytophaga. Domestic dog bite wounds can produce substantial morbidity, and often require specialized care techniques and specific antibiotic therapy. Bite wounds can be complicated by disseminated infections, and particularly those caused by Pasteurella multocida can lead to septic shock, meningitis, endocarditis, and other severe sequelae .

Proposed Bedside Maneuver to Facilitate Accurate Anatomic Orientation for Correct Positioning of ECG Precordial Leads V1 and V2: A Pilot Study - Corrected Proof

Michael H. Lehmann, Aimee M. Katona — 2012-04-16

Abstract: Background: Misplacement of right precordial electrocardiogram (ECG) electrodes superiorly is a prevalent procedural error that may lead to false findings of T-wave inversion or QS complexes in V2—possibly triggering wasteful utilization of health care resources. Standard technique for proper placement of V1–V2 entails initial palpation for the sternal angle, pointing to the second intercostal space (ICS), followed by lead fixation at the fourth ICS.Study Objective: Because adherence to this approach may be limited by lack of a visual landmark for the second ICS, we assessed an alternative technique.Methods: The evaluated technique involved placement of the patient’s hand up against the base of his/her neck (H→N maneuver) to help demarcate visually a specific point “X” on the chest.Results: Of 112 patients studied, “X” landed on the first rib in 2.7%, first ICS in 7.1%, second rib in 56.3%, second ICS in 33.0%, and third rib in 0.9%. Thus, in 89.3% (95% confidence interval 83.6–95.0%) of cases (93.3% of men, 84.6% of women; p=0.13), the second ICS could be identified by H→N via the following simple rule: Utilize “X” if it overlies an ICS; or the immediately subjacent ICS if “X” overlies a rib.Conclusion: The H→N maneuver provides a primarily visual approach to identifying the second ICS and, thereby, the fourth ICS for affixing V1–V2. If the present initial experience is confirmed, H→N might merit consideration as an educational tool to promote anatomically correct placement of these precordial leads, a prerequisite to diminishing the incidence of ECG procedure-related “septal ischemia/infarction.”

Tension Pneumocephalus: An Uncommon Cause of Altered Mental Status - Corrected Proof

Joshua Simmons, Andrew M. Luks — 2012-04-16

Abstract: Background: Pneumocephalus is a rare cause of altered mental status in patients presenting to the Emergency Department. Occurring as a result of traumatic or iatrogenic violation of the dura, it can cause significant morbidity and mortality if tension physiology develops whereby air continues to accumulate with no mechanism for escape.Objective: This case report will review the underlying pathophysiology, clinical presentation, diagnosis, and management of tension pneumocephalus.Case Report: We present the case of an 89-year-old man who presented to the Emergency Department with declining mental status 9h after endoscopic sinus surgery. He was subsequently found to have tension pneumocephalus and underwent emergent burr hole evacuation. Despite resolution of the pneumocephalus, the patient had persistent neurologic deficits related to ischemic infarcts that occurred as a result of the tension physiology and subsequently expired in the hospital.Conclusion: This case illustrates the importance of considering tension pneumocephalus on the differential diagnosis for any patient presenting with altered mental status after surgical or diagnostic procedures with potential to violate the dural space.

Use of Cadaver Models in Point-of-care Emergency Ultrasound Education for Diagnostic Applications - Corrected Proof

Brita E. Zaia, Beau Briese, Sarah R. Williams, Laleh Gharahbaghian — 2012-04-16

Abstract: Background: As the use of bedside emergency ultrasound (US) increases, so does the need for effective US education.Objectives: To determine 1) what pathology can be reliably simulated and identified by US in human cadavers, and 2) feasibility of using cadavers to improve the comfort of emergency medicine (EM) residents with specific US applications.Methods: This descriptive, cross-sectional survey study assessed utility of cadaver simulation to train EM residents in diagnostic US. First, the following pathologies were simulated in a cadaver: orbital foreign body (FB), retrobulbar (RB) hematoma, bone fracture, joint effusion, and pleural effusion. Second, we assessed residents’ change in comfort level with US after using this cadaver model. Residents were surveyed regarding their comfort level with various US applications. After brief didactic sessions on the study’s US applications, participants attempted to identify the simulated pathology using US. A post-lab survey assessed for change in comfort level after the training.Results: Orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion were readily modeled in a cadaver in ways typical of a live patient. Twenty-two residents completed the pre- and post-lab surveys. After training with cadavers, residents’ comfort improved significantly for orbital FB and RB hematoma (mean increase 1.6, p<0.001), bone fracture (mean increase 2.12, p<0.001), and joint effusion (1.6, p<0.001); 100% of residents reported that they found US education using cadavers helpful.Conclusion: Cadavers can simulate orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion, and in our center improved the comfort of residents in identifying all but pleural effusion.

Regarding Suspected Brown Recluse Spider Envenomation Case Report - Corrected Proof

Jeremy D. Joslin — 2012-04-16

Because I live and practice in the same area, indeed the same institution, I read with great interest the recent article titled, “Suspected Brown Recluse Envenomation: A Case Report and Review of Different Treatment Modalities” . Although the review of treatment modalities was thorough and interesting, I do take issue with the author's conclusion that “the most likely etiology was found to be envenomation by a brown recluse spider [BRS], Loxosceles reclusa.” Although the authors did attempt to remain accurate by using “Suspected” in the title, concluding that the lesion described was most likely due to any type of animal bite is a nebulous deduction because the patient is unable to recall the specific time, place, and appearance of an offender. Even if we took for granted that the patient could identify a “bug,” further extemporaneous deduction into the class, order, family, genus, and species of said “bug” is a severely flawed exercise .

A Systematic Review of Patient Tracking Systems for Use in the Pediatric Emergency Department - Corrected Proof

Ian Dobson, Quynh Doan, Geoffrey Hung — 2012-04-16

Abstract: Background: Patient safety is of great importance in the pediatric emergency department (PED). The combination of acutely and critically ill patients and high patient volumes creates a need for systems to support physicians in making accurate and timely diagnoses. Electronic patient tracking systems can potentially improve PED safety by reducing overcrowding and enhancing security.Objectives: To enhance our understanding of current electronic tracking technologies, how they are implemented in a clinical setting, and resulting effect on patient care outcomes including patient safety.Methods: Nine databases were searched. Two independent reviewers identified articles that contained reference to patient tracking technologies in pediatrics or emergency medicine. Quantitative studies were assessed independently for methodological strength by two reviewers using an external assessment tool.Results: Of 2292 initial articles, 22 were deemed relevant. Seventeen were qualitative, and the remaining five quantitative articles were assessed as being methodologically weak. Existing patient tracking systems in the ED included: infant monitoring/abduction prevention; barcode identification; radiofrequency identification (RFID)- or infrared (IR)-based patient tracking. Twenty articles supported the use of tracking technology to enhance patient safety or improve efficiency. One article failed to support the use of IR patient sensors due to study design flaws.Conclusions: Support exists for the use of barcode-, IR-, and RFID-based patient tracking systems to improve ED patient safety and efficiency. A lack of methodologically strong studies indicates a need for further evidence-based support for the implementation of patient tracking technology in a clinical or research setting.

A Pneumomediastinum with Diffuse Subcutaneous Emphysema - Corrected Proof

Emilie Dehours, Baptiste Vallé, Vincent Bounes, Dominique Lauque — 2012-04-16

A 65-year-old man presented to the Emergency Department with facial angioedema. It occurred just after an intramuscular morphine injection in the shoulder for a minor chest trauma from falling off a chair. On physical examination, he had right chest pain, a pulse of 90 beats/min, blood pressure of 140/80 mm Hg, respiratory rate of 35 breaths/min, and room air oxygen saturation of 88%. Diffuse wheezes were detectable in both lungs. He was provided with supplemental oxygen, salbutamol aerosol, and corticosteroid treatment. After initial stabilization, subcutaneous emphysema developed suddenly over his chest. Chest radiography revealed a right lucency, some mediastinal radiolucent streaks, and subcutaneous emphysema (). Chest computed tomography scan with intravenous contrast confirmed the right pneumothorax and the pneumomediastinum (), and revealed a rib fracture (). A chest drain was inserted and the patient’s condition improved.

Traumatic Gallbladder Rupture - Corrected Proof

Benjamin C. Chastain, Rawle A. Seupaul — 2012-04-16

A 50-year-old man presented to our Emergency Department (ED) after being involved in a single-vehicle motor vehicle collision with a tree at approximately 40 mph, which required a 10-min extrication. The patient was a restrained driver and airbags were deployed. The patient complained of diffuse abdominal pain with maximal intensity in the right upper quadrant. The patient was alert on ED presentation, initial temperature was 36°C, heart rate was 115 beats/min, respiratory rate was 28 breaths/min, blood pressure was 112/84 mm Hg, and oxygen saturation was 98% on room air. Physical examination was notable for a soft, nondistended diffusely tender abdomen, tenderness with palpation of the chest wall, and bruising along the upper abdomen. Chest, abdominal, and pelvis computed tomography (CT) scans were obtained and showed a large amount of low-density fluid surrounding the gallbladder and discontinuity of the gallbladder wall. The patient was admitted to the trauma service and initially managed conservatively. During the patient’s hospital stay, he continued to have right upper quadrant pain and developed a leukocytosis and fever. At this point, another CT scan was obtained that demonstrated a persistent defect in the gallbladder wall with increased pericholecystic fluid collection (). Ultrasound-guided drainage of this fluid collection was bilious. Endoscopic retrograde cholangiopancreatography identified a persistent biliary leak, which resolved after placement of a common bile duct stent.

Acute Hand Ischemia after Intra-arterial Injection of Meprobamate Powder - Corrected Proof

Chen-Ken Seak, Xiu-Jin Kooi, Chen-June Seak — 2012-04-12

Abstract: Background: Meprobamate tablets contain microcrystalline cellulose, a potent embolic agent that has been shown to cause gangrene in animal studies. Microvascular embolization caused by microcrystalline cellulose can contribute to the ischemic process.Objective: We report a case of acute hand ischemia after accidental intra-arterial injection of crushed meprobamate powder in a 23-year-old male drug abuser.Case Report: The distal tips of the patient’s right thumb, index finger, ring finger, and little finger continued to develop gangrene despite medical therapy with heparinization, low molecular-weight dextran infusion, corticosteroid administration, and hyperbaric oxygen therapy.Conclusion: We believe this is the first case of acute limb ischemia caused by intra-arterial injection of meprobamate powder documented in humans. Emergency physicians should be aware that accidental intra-arterial injection of crushed oral drug formulations is potentially limb threatening and prompt recognition of similar clinical scenarios is of vital importance.

MRSA Rates and Antibiotic Susceptibilities from Skin and Soft Tissue Cultures in a Suburban ED - Corrected Proof

Andrew Wackett, Andrei Nazdryn, Eric Spitzer, Adam J. Singer — 2012-04-11

Abstract: Background: Prior studies suggest that more than half of all skin and soft tissue infections (SSTIs) are caused by methicillin-resistant Staphylococcus aureus (MRSA). These data mainly represent inner-city urban centers.Objective: We determined the bacteriologic etiologies and antibiotic susceptibilities from wound cultures in the emergency department (ED). We hypothesized that in a suburban ED, MRSA would not represent the major pathogen.Methods: The study design was a retrospective, electronic medical record review in a suburban tertiary care ED with 80,000 annual visits. Subjects included ED patients of all ages who had skin or soft tissue cultures obtained in 2005–2008. Demographics and clinical data, including type of SSTI (MRSA or methicillin-sensitive S. aureus [MSSA]), culture results, and antibiotic susceptibility, were analyzed using descriptive statistics.Results: From the 1246 cultures obtained during the study period, 252 (20.2%) were MSSA and 270 (21.6%) were MRSA. The rates of MRSA infections over time increased from 13.5% to 25.7% during 2005–2008. The rates of MRSA in males and females were comparable at 23.3% and 19.6%, respectively. In 2008, MRSA was 97–100% susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, chloramphenicol, gentamycin, tetracycline, and trimethoprim-sulfamethoxazole (TMP-SMZ). To a lesser extent it was susceptible to clindamycin (75%), erythromycin (62%), and levofloxacin (50%).Conclusions: There has been a significant increase in the rates of MRSA SSTIs in a suburban ED, yet only 1 in 4 SSTIs are caused by MRSA. Both MRSA and MSSA are completely susceptible to vancomycin, linezolid, rifampin, nitrofurantoin, and chloramphenicol. Gentamicin, tetracycline, and TMP-SMZ cover > 97% of both isolates.

A Melioidosis Patient Presenting with Brainstem Signs in the Emergency Department - Corrected Proof

Chia-Te Kung, Chao-Jui Li, Sheung-Fat Ko, Chen-Hsiang Lee — 2012-04-11

Abstract: Background: Neurological abnormalities in melioidosis are rare but may manifest as an acute stroke, and in the emergency department (ED), an inappropriate stroke treatment may threaten a patient’s life.Objectives: A case of cerebral melioidosis is reported in a patient presenting with brainstem signs to increase awareness of the uncommon presentations of melioidosis that may cause a delayed diagnosis in the ED.Case Report: A 45-year-old man who worked as a construction worker, with diabetes mellitus and alcoholic liver cirrhosis, presented to the ED after a 10-day period of fever and cough. He was initially diagnosed and treated as a case of community-acquired pneumonia. However, a sudden change in consciousness with 6th and 7th cranial nerve palsy and flaccid paralysis were noted while he was in the ED, and acute brainstem stroke was suspected. Brain magnetic resonance imaging disclosed brainstem lesions, slightly hypointense on T1-weighted images and hyperintense on T2-weighted images. Blood and urine cultures subsequently yielded Burkholderia pseudomallei. Abdominal computed tomography revealed multiple small consolidated patches, ground-glass opacities, small nodules in the lower lungs bilaterally, and a pancreatic tail abscess. Systemic melioidosis with lung, pancreas, urogenic tract, and brainstem involvement was diagnosed. Three weeks after admission, the patient died from a sudden onset of apnea and asystole.Conclusions: In light of this case, patients with identifiable risk factors, especially underlying diabetes, a history of positive soil contact, and those who lived in an endemic area or ever traveled to an endemic area, and who present themselves with fever and neurologic deficit or multi-organ involvement, should have melioidosis considered in the differential diagnosis.