The Journal of Emergency Medicine - Articles in Press

Use of a Structural Deformity Index as a Predictor of Severity among Trauma Victims in Motor Vehicle Crashes - Corrected Proof

2010-03-08

Abstract: Background: Information obtained from vehicle crash scenes, called kinematics, may prove useful in the management of victims and may complement anatomical and physiological findings. Objectives: In addition to analyzing the significance of age, gender, position occupied in the vehicle, the use of restraint systems, and ejection from the vehicle, the objective was to carry out a preliminary study of what we have defined as the Structural Deformity Index (SDI) to verify its usefulness in predicting injury severity at the scene of a motor vehicle crash. The index consists of various parameters that can be easily identified at the crash scene. Method: An historical cohort of vehicle occupants involved in crashes in the Navarra province of Spain from January 1, 2001 to December 31, 2002 was studied. Information was collected from the database of the Navarra Severe Trauma Victim group study. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management. Results: There were 212 vehicle occupants identified. Significant differences in severity of injury, and of mortality, were observed based on age, ejection from the vehicle, and a high SDI. Logistic regression showed significant differences in injury severity by age (odds ratio [OR] 6.55, 95% confidence interval [CI] 1.6–26.7) and high SDI (OR 1.84, 95% CI 1–3.3), as well as differences in the patient death rate by age (OR 6.92, 95% CI 1.2–38.9) and high SDI (OR 3.28, 95% CI 1.5–6.8). Conclusions: The SDI is useful to the first responders, enabling them to alert and transmit objective, reliable information to the emergency coordination center, thus efficiently activating health care resources. In addition, use of the SDI may assist prehospital and hospital health care providers to suspect the presence of particular serious injuries when anatomical and physiological criteria are not definitive.

Bedside Estimation of Patient Height for Calculating Ideal Body Weight in the Emergency Department - Corrected Proof

2010-03-02

Abstract: Background: Ideal body weight (IBW), which can be calculated using the variables of true height and sex, is important for drug dosing and ventilator settings. True height often cannot be measured in the emergency department (ED). Objectives: Determine the most accurate method to estimate IBW using true height-based IBW that uses true height estimated by providers or patients compared to true height estimated by a regression formula using measured tibial length, and compare all to the conventional 70 kg male/60 kg female standard IBW. Methods: Prospective, observational, double-blind, convenience sampling of stable adult patients in a tertiary care ED from September 2004 to April 2006. Derivation set (215 patients) had blinded provider and patient true height estimates and tibial length measurements compared to gold-standard standing true height. A validation set (102 patients) then compared the accuracy of IBW using true height calculated from the regression formula vs. IBW using gold-standard true height. Regression formula for men tibial length-IBW (kg) = 25.83 + 1.11 × tibial length; for women tibial length-IBW = 7.90 + 1.20 × tibial length; R2 = 0.89, p < 0.001. Inter-rater correlation of tibial length was 0.94. Results: Derivation set: percent within 5 kg of true height-based IBW for men/women = Patient: 91.1%:/85.7%; Physician: 66.1%/45.1%; Nurse: 65.7%/ 47.3%; tibial length: 66.1%/63.7%; and 70 kg male/60 kg female standard 46%/75%. Validation set: tibial length-IBW estimates were within 5 kg of true height-ideal body weight in only 56.2% of men and 42.2% of women. Conclusions: Patient-reported height is the best bedside method to estimate true height to calculate ideal body weight. Physician and nurse estimates of true height are substantially less accurate, as is true height obtained from a regression formula that uses measured tibial length. All methods were more accurate than using the conventional 70 kg male/60 kg female IBW standard.

Detection and Localization of Peripheral Vascular Bleeding Using Doppler Ultrasound - Corrected Proof

2010-03-02

Abstract: Background: Hemorrhage from wounds in the extremities is the leading cause of preventable death on the battlefield. To successfully treat these injuries, the exact source of bleeding must be localized. Objective: The purpose of this study was to determine the feasibility of using Doppler ultrasound to precisely detect and localize peripheral vascular bleeding. Methods: Injuries were produced in common femoral arteries (diameter of ∼5 mm) of 28 pigs in vivo. Single puncture injuries were produced using 6 French (F) (n = 10), 9 F (n = 22), and 12 F (n = 12) catheters. In addition, multiple punctures were made (using 6 F and 9 F catheters) in eight common femoral arteries to simulate bleeding from multiple injuries. Finally, laceration injuries were produced using a scalpel in 10 femoral vessels. Results: In color Doppler images, bleeding was observed as a turbulent jet flow originating from the injury site in the vessel. This jet flow had checkered red-blue color pattern at the bleeding site, as opposed to a uniform color pattern in an intact artery. Peak systolic velocity at the injury site, measured using pulsed Doppler, was elevated to up to 152.0 ± 81.6 cm/s, as compared to 78.8 ± 17.5 cm/s in normal arteries. Further, end diastolic velocity increased from 6.1 ± 4.9 cm/s before the injury to up to 59.1 ± 33.1 cm/s after the injury. Resistance index was significantly lower (0.6 for 9 F and 12 F punctures, and 0.8 for 6 F punctures) at the bleeding site in injured arteries as compared to the resistance index of intact arteries (of 0.9). Conclusion: Our results showed a characteristic change in the systolic and diastolic velocities, as well as resistance indices at the injury site in peripheral arteries. These findings may serve as groundwork for development of automated bleeding detection and localization methods, and facilitate various hemorrhage control treatments.

Co-occurrence of Diaphragmatic and Serratus Anterior Muscle Hydatidosis: An Unusual Localization - Corrected Proof

Abdullah Ozgonul, Ozgur Sogut, Hasan Cece, Salih Aydın, Ibrahim Can Kürkcüoglu — 2010-03-02

Abstract: Background: With hydatid cyst, the skeletal muscles and diaphragm are rarely affected, and hepatic and pulmonary hydatid cysts are far more common. We report a case with an unusual localization of diaphragmatic and serratus muscle anterior hydatidosis that occurred simultaneously. Case Report: A 37-year-old developmentally disabled woman presented to the Emergency Department (ED) of Harran University with tachycardia, tachypnea, and dyspnea. On pulmonary auscultation, breath sounds were decreased on the right side. A chest X-ray study revealed a radiopaque right hemithorax with a mediastinal shift and tracheal displacement. Thoracic computed tomography scan revealed a hydatid cyst in the serratus muscle anterior and cystic vesicles in the pleural cavity. The patient underwent chest drainage. During drainage, daughter vesicles within the pus were detected macroscopically. An elective thoracotomy was performed after hemodynamic stabilization of the patient. Postoperative chest X-ray study demonstrated that the lungs had re-expanded. The patient had no postoperative complications and was discharged with relief of all symptoms. Conclusion: Hydatid cyst should be considered, especially in endemic regions, in the differential diagnosis in the presence of a rare localization or unexpected clinical presentation. Surgical intervention is the appropriate approach for the treatment of hydatid cyst when there is concomitant intrathoracic involvement.

Maisonneuve Fracture Sometimes Needs Stress View - Corrected Proof

Rafid Kakel — 2010-03-02

In the article titled “Maisonneuve Fracture” by Millen and Lindberg, which appeared in The Journal of Emergency Medicine, January 2009, it states: “An intact mortise with no joint space widening can be treated by casting and follow-up with Orthopedics in 6–8 weeks. A mortise that is not in anatomic alignment requires open reduction” ().

Cyanide Poisoning and Cardiac Disorders: 161 Cases - Corrected Proof

2010-02-25

Abstract: Background: Inhalation of hydrogen cyanide from smoke in structural fires is common, but cardiovascular function in these patients is poorly documented. Objective: The objective was to study the cardiac complications of cyanide poisoning in patients who received early administration of a cyanide antidote, hydroxocobalamin (Cyanokit®; Merck KGaA, Darmstadt, Germany [in the United States, marketed by Meridian Medical Technologies, Bristol, TN]). Methods: The medical records of 161 fire survivors with suspected or confirmed cyanide poisoning were reviewed in an open, multicenter, retrospective review of cases from the Emergency Medical Assistance Unit (Service d'Aide Médical d'Urgence) in France. Results: Cardiac arrest (61/161, 58 asystole, 3 ventricular fibrillation), cardiac rhythm disorders (57/161, 56 supraventricular tachycardia), repolarization disorders (12/161), and intracardiac conduction disorders (5/161) were observed. Of the total 161 patients studied, 26 displayed no cardiac disorder. All patients were given an initial dose of 5 g of hydroxocobalamin. Non-responders received a second dose of 5 g of hydroxocobalamin. Of the patients initially in cardiac arrest, 30 died at the scene, 24 died in hospital, and 5 survived without cardiovascular sequelae. Cardiac disorders improved with increasing doses of hydroxocobalamin, and higher doses of the antidote seem to be associated with a superior outcome in patients with initial cardiac arrest. Conclusions: Cardiac complications are common in cyanide poisoning in fire survivors.

Past-year intentional and unintentional injury among teens treated in an inner-city emergency department - Corrected Proof

2010-02-11

Abstract: An inner-city emergency department (ED) visit provides an opportunity for contact with high-risk adolescents to promote injury prevention. Objectives: To identify the prevalence of injuries sustained over the past year by teens presenting to an inner-city ED, and to identify factors associated with recent injury to inform future ED-based injury prevention initiatives. Methods: Over 1 year, 7 days a week, from 1:00–11:00 p.m., patients aged 14–18 years presenting to the ED participated in a survey regarding past-year risk behaviors and injuries. Results: Of the entire group of teens presenting to the ED (n = 1128) who completed the survey (83.8% response rate), 46% were male, and 58% were African-American. Past-year injuries were reported by 768 (68.1%) of the teens; 475 (61.8%) of those reported an unintentional injury and 293 (38.1%) reported an intentional injury. One-third of all youth seeking care reported a past-year sports-related injury (34.5%) or an injury related to driving or riding in a car (12.3%), and 8.2% reported a gun-related injury. Logistic regression found that binge drinking (adjusted odds ratio [AOR] 1.95) and illicit weapon carrying (AOR 2.31) predicted a past-year intentional injury. African-American youth (AOR 0.56) and those receiving public assistance (AOR 0.73) were less likely to report past-year unintentional injuries. Conclusions: Adolescents seeking care in an inner-city ED, regardless of the reason for seeking care, report an elevated prevalence of recent injury, including violence. Future injury screening and prevention efforts should consider universal screening of all youth seeking ED care.

Isolated Adrenal Hematoma Presenting as Acute Right Upper Quadrant Pain - Corrected Proof

Kalil G. Abdullah, Russell N. Stitzlein, Thomas A. Tallman — 2010-02-08

Abstract: Background: Adrenal hematoma is an infrequent occurrence in the setting of adult trauma care. It is typically associated with diffuse abdominal injury, and its presence is commonly correlated with high injury severity and mortality. Objectives: To discuss the recognition of adrenal hematoma as a cause of right upper quadrant pain. Case Report: We present the case of a 23-year-old man who presented to the Emergency Department (ED) with acute right upper quadrant pain after blunt trauma to the area; he was initially diagnosed with an abdominal contusion with an incidental adrenal adenoma. After experiencing continued pain for 2 days, the patient returned to the ED for re-evaluation. Subsequent imaging revealed that the adrenal mass had enlarged, and it was determined that this patient had suffered an acute adrenal hematoma. The lesion was determined to be self-limited and the patient was treated with supportive care. Follow-up images 8 weeks later revealed resolution of the hematoma and the patient reported complete resolution of symptoms. We also discuss adrenal hematoma in the trauma setting and explain that in our patient, given the clinical scenario and statistical evidence, an initial diagnosis of adrenal hematoma should be favored over abdominal contusion with incidental adenoma. Conclusion: We describe a case of a traumatic isolated adrenal hematoma that presents acutely as right upper quadrant pain. This unusual presentation highlights the need for recognition of the adrenal gland as a potential cause of right upper quadrant pain in the trauma setting.

Niacin Toxicity Resulting From Urine Drug Test Evasion Scheme - Corrected Proof

Anne M. Daul, Michael C. Beuhler — 2010-02-08

Abstract: Background: Niacin, a well-established agent for treating dyslipidemia, has been promoted on the Internet as a method for passing urine drug screening, although there are no data to support its use for this purpose. In a handful of cases, this practice has resulted in serious niacin toxicity. Objectives: The aim of this article is to describe a unique clinical presentation of niacin toxicity. Case Report: A 23-year-old previously healthy man presented to an Emergency Department with altered mental status, fever, acute renal failure, microangiopathic hemolytic anemia, thrombocytopenia, and coagulopathy. It was revealed that he had taken approximately 22.5 g of sustained-release niacin over the preceding 48 h in an attempt to pass a pre-employment urine drug screen. After a complicated hospital course that included mechanical ventilation for respiratory failure and hemodialysis for acute renal failure, the patient made a full recovery and was discharged 10 days after his initial presentation. Conclusion: After a massive niacin overdose, the young man in this case presented with a complex clinical picture that mimicked concurrent thrombotic thrombocytopenic purpura and disseminated intravascular coagulation. Although this patient was fortunate to make a full recovery, the case highlights the potential for multi-system toxicity with niacin overdose, and the potential for harm posed by medical misinformation on the Internet.

TASER Device-induced Rhabdomyolysis is Unlikely - Corrected Proof

Jeffrey D. Ho, Donald M. Dawes — 2010-02-08

We read with interest the Case Report by Sanford and colleagues of two subjects subdued by TASER devices (). We believe that this Clinical Communication reports correctly that, in general, people with behavior rising to a certain escalated level of combativeness or agitation are more likely to be the recipients of a TASER device application for control and restraint and that they may have some underlying medical conditions that need to be further evaluated (such as intoxication, delirium, or uncontrolled psychosis).

Violence in the Emergency Department: A National Survey of Emergency Medicine Residents and Attending Physicians - Corrected Proof

Marcelina Behnam, Roger D. Tillotson, Stephen M. Davis, Gerald R. Hobbs — 2010-02-05

Abstract: Background: Violence in the Emergency Department (ED) is a well-known phenomenon. Few studies have been done to assess the incidence and nature of violence in the ED. Study Objectives: The purpose of this study was to assess the incidence of violence in the ED nationwide. Methods: This study was a prospective, cross-sectional online survey of Emergency Medicine (EM) residents and attending physicians. Of the 134 accredited United States (US) EM residency programs, 65 programs were randomly selected and invited to participate. Results: Overall, 272 surveys were returned, of which 263 (97%) were completed and further analyzed. At least one workplace violence act in the previous 12 months was reported by 78% (95% confidence interval 73–83%) of respondents, with 21% reporting more than one type of violent act. Workplace violence was experienced similarly between males and females (79% vs. 75%, respectively; p = 0.65), and was more common in EDs with annual volumes over 60,000 patients (82% vs. 67%; p = 0.01). The most common type of workplace violence was verbal threats (75%) followed by physical assaults (21%), confrontations outside the workplace (5%), and stalking (2%). Security was available full time in most settings (98%), but was least likely to be physically present in patient care areas. The majority of respondent EDs did not screen for weapons (40% screened) or have metal detectors (38% had metal detectors). Only 16% of programs provided violence workshops, and less than 10% offered self-defense training. Conclusion: Despite the high incidence of workplace violence experienced by the emergency physicians who responded to our survey, less than half of these respondents worked in EDs that screened for weapons or had metal detectors. An even smaller number of physicians worked in settings that provided violence workshops or self-defense training.

Prevention and Sporadic Carbon Monoxide Poisoning Related to Shisha (Hookah, Narghile) Tobacco Smoking - Corrected Proof

Kamal Chaouachi — 2010-02-05

Fortunately, carbon monoxide (CO) poisoning due to shisha (hookah, narghile) smoking is rather rare, and, when it happens here and there, it is due to the absence, for more than 10 years, of a modern tobacco harm reduction preventive educational program. We would like to inform Uyanik and his team of two other reported cases in the world (). The first was described by Lim et al. in Singapore and the other in France, a country known for having, as of 2 years ago, a total of about one thousand neo-orientalist narghile smoking tea houses (). The main source of the high registered CO levels is the charcoal used to heat the smoking mixture at the top of the pipe. Traditionally, in Asia and Africa, smoking takes place in the open air or in well-ventilated venues. Indeed, Eastern and European cafes are very different in this respect. Most of the time, the sporadic poisonings are due to the absence of efficient ventilation where hookah, generally with cigarette, smoking is performed. Unfortunately, public health prevention messages clearly mentioning the CO hazards related to hookah smoking have never been issued. Interventions have unsuccessfully been targeting eradication of use (). Notably, reported COHb concentrations from hookah smoking generally range between 20% and 30%: Uyanik et al. report 28.7%; Lim et al. and Levant et al. reported 27.8% and 20.8%, respectively ().

Emergency Medicine Interest Group Curriculum: Faculty and Preclinical Student Opinions Differ in a Formal Needs Assessment - Corrected Proof

Carol Lee, Sebastian Uijtdehaage, Wendy C. Coates — 2010-02-01

Abstract: Background: Medical students and Emergency medicine (EM) faculty may have differing opinions on the ideal curriculum during the preclinical years. Objectives: To assess the perceived needs of preclinical medical students exploring EM and compare them with those of EM faculty regarding appropriate educational interventions. Methods: A survey instrument listing 15 workshops related to EM was administered to preclinical medical students in our Emergency Medicine Interest Group (EMIG), and to EM faculty. Respondents graded the perceived utility of each workshop offered at our medical school and those identified via a web search for EMIG. No recommendations for EMIG curriculum were identified through PubMed. Fisher's exact tests were computed using SPSS (SPSS Inc., Chicago, IL) with α = 0.05. Results: There were 48 medical students and 15 faculty members who completed the survey. Students strongly desired workshops in suturing (48/48; 100%), splinting (47/48; 97.9%), and basic electrocardiogram (ECG) interpretation (47/48; 97.9%). Least desired topics were history of EM (16/48; 33.3%), getting involved in EM organizations (20/48; 41.7%), and wellness (21/48; 43.8%). Women chose the domestic violence workshop more than men (p = 0.036). Faculty strongly supported workshops in conducting focused history and physical examination (14/15; 93.3%), the specialty of EM (14/15; 93.3%), and basic ECG interpretation (12/15; 80.0%). The lowest rated faculty preferences were ultrasound (5/15; 33.3%), history of EM (7/15; 46.7%), and emergency radiology (7/15; 46.7%). Conclusions: Preclinical students and faculty opinions of important educational workshops differed. Faculty favored the approach to the undifferentiated patient and an introduction to the specialty, whereas students preferred hands-on workshops. Both groups agreed that basic ECG interpretation was useful. These data may be useful for designing an educational program that is interesting to preclinical students while still meeting the needs as perceived by medical student educators.

Association of Trichomonas Infection with Gonorrhea or Chlamydia - Corrected Proof

Richard Gentry Wilkerson — 2010-02-01

I read with great interest the recent article by Wegner et al. regarding the association of infection with Trichomonas vaginalis with concurrent infection with either Neisseria gonorrhea or Chlamydia trachomatis (). Sexually transmitted diseases pose a diagnostic dilemma for the Emergency Physician. The laboratory turnaround time often precludes the definitive diagnosis during the same patient visit. Thus, one may be left with either a return visit or treatment based on the best evidence available.

Medical clearance of the psychiatric patient in the emergency department - Corrected Proof

Bruce D. Janiak, Suzanne Atteberry — 2010-02-01

Abstract: Background: As part of the emergency department (ED) evaluation of patients with psychiatric complaints, emergency physicians are often asked to perform screening laboratory tests prior to admitting psychiatric patients, the value of which is questionable. Study Objective: To determine if routine screening laboratory studies performed in the ED on patients with a psychiatric chief complaint would alter ED medical clearance (evaluation, management or disposition) of such patients. Methods: In this retrospective chart review, the patient charts were reviewed for triage notes, history and physical examination, laboratory study results, and patient disposition. The study investigators subjectively determined if any of the laboratory abnormalities identified after admission would have changed ED management or disposition of the patient had they been identified in the ED. Results: Subjects were 519 consecutive adult patients (18 years of age and older) admitted to the Medical College of Georgia's inpatient psychiatric ward through the ED. There were 502 patients who met inclusion criteria, and 50 of them had completely normal laboratory studies. Laboratory studies were performed in the ED for 148 patients. The most common abnormalities identified were positive urine drug screen (n = 221), anemia (n = 136), and hyperglycemia (n = 139). There was one case (0.19%) identified in which an abnormal laboratory value would have changed ED management or disposition of the patient had it been found during the patient's ED visit. Conclusions: Patients presenting to the ED with a psychiatric chief complaint can be medically cleared for admission to a psychiatric facility by qualified emergency physicians using an appropriate history and physical examination. There is no need for routine medical screening laboratory tests.

Introduction of the conducted electrical weapon into a hospital setting - Corrected Proof

2010-02-01

Abstract: Background: The TASER® X26 Conducted Electrical Weapon (CEW) provides painful stimuli and neuromuscular incapacitation to potentially violent persons. Use by law enforcement in society is common. Presenting a CEW is known to de-escalate some situations. Health care personnel sometimes encounter violent persons within the confines of the hospital. CEW use by health care security personnel has not been described. Objective: The objective is to describe results from the introduction of the CEW into a hospital environment. Methods: Upon introducing the CEW into an urban hospital campus, standardized reports were made describing all CEW use by hospital security. Reports were retrospectively reviewed for the first 12 months of CEW use. Collected data included force options used, potential injuries avoided, witness comments, outcomes, and whether the CEW required full activation or if inactive presentation was sufficient to control the situation. Rates of security personnel injuries were also gathered. Descriptive analysis was applied. Results: Twenty-seven CEW deployments occurred: four were inactive presentation, 20 were presentation with LASER sight activation, and three were probe deployments with a 5-s delivery of electrical current. Two persons required evaluation for minor injuries not related to CEW use. Witnesses reported that in all incidents, injuries were likely avoided due to CEW presentation or use. CEW use aborted one suicide attempt. Personnel injury rates decreased during the study period. Conclusion: CEW introduction into a health care setting demonstrated the ability to avert and control situations that could result in further injury to subjects, patients, and personnel. This correlates with a decrease in injury for hospital personnel. Further study is recommended for validation.

Causality and Emergency Medicine? - Corrected Proof

Alexis Descatha — 2010-02-01

The main goal of emergency medicine is to recognize and treat acute medical conditions and then to make an appropriate disposition (admit to a specific hospital unit or discharge home). The process for making a diagnosis and selecting a therapeutic option is well known by emergency physicians. However, the etiology of a given disorder is usually considered less important by emergency physicians, who believe that such considerations can wait and be performed in the appropriate unit (if the patient is hospitalized) or in a primary care setting. A good illustration of this is the significantly lower proportion of literature citations in PubMed of the term “causality” in the emergency medicine literature compared to some other medical specialties (). However, considering causality in the diagnostic process, as well as severity of distress, may improve the accuracy of the diagnosis (by significantly changing the post-test probability) or the choice of therapy. For instance, in the case of a patient complaining of acute chest pain, the evaluation of a possible acute coronary syndrome should include an assessment for evidence of atherosclerosis and its risk factors. The presence (or absence) of certain risk factors significantly modifies the probability of acute coronary syndrome (). Early treatment for acute coronary syndrome includes atherosclerosis management as well. There are other examples for which risk factors are clearly identified and the diagnosis is not simple (e.g., deep venous thrombosis risk factors in the diagnosis of pulmonary embolism, or specific allergen exposure and asthma) (). The search for risk factors in the early phase of care can improve the diagnosis and assist in selecting appropriate treatments. Further studies are needed to assess how causality can improve diagnostic accuracy in emergency care.

Furuncular Myiasis from Dermatobia hominus: A Case of Human Botfly Infestation - Corrected Proof

Jacqueline J. Mahal, Jeremy D. Sperling — 2010-02-01

Abstract: Background: Travelers to tropical regions are at risk for a myriad of exotic illnesses. Malaria and dengue are diagnoses that are associated with insect bites, in particular, mosquito bites, acquired while traveling in foreign, tropical countries. Infestation with Dermatobia hominus, the human botfly, endemic to South and Central America, is usually transferred via a mosquito vector. The human botfly should be considered in patients who have traveled to these endemic regions and present with a mosquito bite history and non-healing skin lesions. Objectives: We present this case to increase awareness among emergency physicians regarding furuncular myiasis from the human botfly. Case Report: A 39-year-old pregnant woman presented to the Emergency Department (ED) with an intensely pruritic lesion to the right calf and mild systemic symptoms 6 weeks after travel to Belize. The lesion she thought was a mosquito bite had persisted despite escalating treatment modalities and had been incorrectly diagnosed by multiple physicians. Conclusion: Parasitic disease is not always a systemic process. Botfly infestation presents as local boil-like lesions that are irritating and uncomfortable. Once correctly identified, it can be easily treated in the ED.

Blunt Trauma Patients Require a Pelvic Stability Examination - Corrected Proof

Scott D. Weingart — 2010-02-01

A study from the trauma literature was recently abstracted in the Journal of Emergency Medicine by Dr. Krier, with a Comment after the abstract (Editor's Note: the Comments to abstracts are written by the Section Editor of the Abstracts section, Jeffrey Sankoff, MD). The Comment concluded that the pelvic examination before the radiology evaluation may not be helpful in patients with pain, tenderness, or poor mental status (). The primary reason to perform a pelvic ring stability examination in a blunt trauma patient is to assess for the need for pelvic reduction. Each blunt trauma patient should have a single examination by an experienced provider. The examination should consist solely of inward pressure toward the midline with hands placed on the anterior superior iliac spine. If the pelvis moves under the examiner's hands, pressure should be maintained and a bed sheet should be tied around the patient's greater trochanters. Alternatively, a commercial pelvic binder can be applied (). This maneuver will reduce venous bleeding into the retroperitoneum and should be undertaken as soon as possible in an open book pelvic fracture. The number of patients in this abstracted study with unstable open book pelvic fractures (Tile Class B1) was only 8, making the precision of sensitivity or specificity in this particular group poor, though the specificity in unstable fractures in general was high (99%) (). Waiting for radiologic evaluation in this patient group can lead to continued hemorrhage and progression of the lethal triad.

Reply to Wilkerson - Corrected Proof

Michael D. Witting — 2010-01-28

I appreciate the comments by Dr. Wilkerson, who has rightfully pointed out the lack of sensitivity of the wet prep in the diagnosis of infection with Trichomonas vaginalis. In my opinion, this lack of sensitivity does not invalidate our results.

Portable ultrasound for remote environments, part i: Feasibility of field deployment - Corrected Proof

Bret P. Nelson, Edward R. Melnick, James Li — 2010-01-25

Abstract: Background: In field medical operations, rapid diagnosis and triage of seriously injured patients is critical. With significant bulk and cost constraints placed on all equipment, it is important that any medical devices deployed in the field demonstrate high utility, durability, and ease of use. When medical ultrasound was first used in patient care, machine cost, bulk, and steep learning curves prevented use outside of the radiology department. Now, lightweight portable ultrasound is widely employed at the bedside by emergency physicians. The techniques and equipment have recently been extrapolated out of the hospital setting in a wide variety of environments in an effort to increase diagnostic accuracy in the field. Objectives: In this review, deployment of lightweight portable ultrasound in the field (by emergency medical services, military operations, disaster relief, medical missions, and expeditions to austere environments) is examined. The feasibility of field deployment and experiences of clinicians using ultrasound in a host of environments are detailed. In addition, special technological considerations such as telemedicine and machine characteristics are reviewed. Conclusions: The use of lightweight portable ultrasound shows great promise in augmenting clinical assessment for field medical operations. Although the feasibility of the technology has been demonstrated in certain medical and trauma applications, further research is needed to determine the utility of ultrasound use for medical illness in the field.

Prehospital Emergency Care in Hungary: What Can We Learn from the Past? - Corrected Proof

2010-01-25

Abstract: Background: In Hungary, prehospital emergency medical services are provided by the National Ambulance Service. The 60th anniversary of the National Ambulance Service provides a good opportunity to give an overview of the current trends in prehospital emergency medical care in Hungary. Objectives: In this report, a description of the organizational structure and the latest developments in the National Ambulance Service are described with the intention to highlight future directions in emergency medical services, as well as the influence of international trends in emergency patient care. Results: In Hungary, the ambulance cars are staffed by two or three crew members trained in rescue, stabilization of the patient's status, transport, and advanced care of traumatic and medical emergencies. There are three major levels of care provided by ambulance personnel: a basic level ambulance crew (Emergency Medical Technician Unit), a second level (Ambulance Officer Unit), and the highest level (Emergency Physician Unit). The personnel on the latter two units are trained in all aspects of Basic Life Support and Advanced Life Support procedures for prehospital emergency care. Following the latest international developments in medical rescue devices and guidelines, all staff are retrained yearly. Recently, private services for transportation for non-acute illnesses have been introduced, allowing the National Ambulance Service to concentrate on emergencies only. Conclusions: Although the Hungarian Ambulance Service has a very long and meaningful past and a respected professional development, new challenges facing prehospital emergency care are inevitable and continuous development is necessary.

Unique Method of Ocular Ultrasound Using Transparent Dressings - Corrected Proof

Kevin R. Roth, Gregory Gafni-Pappas — 2010-01-25

Abstract: Background: Utilizing bedside ocular ultrasound to aid in diagnosing pathology such as retinal detachment, lens disruption, ocular foreign bodies, or increased intracranial pressure is becoming more pervasive in the Emergency Department. To eliminate an air interface, one must apply ultrasound gel between the patient's skin and the probe. In ocular ultrasound, this practice results in discomfort for the patient as gel seeps into their eyes. To limit patient discomfort, many physicians do not apply a sufficient amount of gel for the examination. This can result in decreased image quality and may cause the ultrasonographer to apply greater pressure to the eye to obtain a satisfactory image. This can be harmful to patients with a ruptured globe and may also be painful to the patient. Discussion: Traditionally, the first step in ocular ultrasound is to place a generous amount of water-soluble ultrasound gel on the eyelid to eliminate the air interface. The authors promote a different and simple technique. A transparent dressing is placed over a closed eye. A generous amount of ultrasound gel is applied to the dressing. A linear ultrasound probe is then placed on the gel and a standard ultrasound scan is obtained. Transparent dressings, which are used as sterile coverings for i.v. sites, have been found to allow satisfactory ultrasound transmission. These products remove the air interface between the eyelid and the dressing. This allows ultrasound gel to be placed on the transparent dressing and not directly on the eyelid, potentially eliminating discomfort for the patient, and creating an easier cleanup. Because a generous amount of ultrasound gel is applied, the ultrasonographer is able to apply minimal pressure on the eye to complete the study, which may decrease harm to the patient's eye. When finished, the transparent dressing is removed. There is no cleanup or patient irritation. Conclusion: This article demonstrates a unique method of ocular ultrasound. The technique can be easily incorporated into emergency bedside ocular ultrasound.

Patients leaving against medical advice (AMA) from the emergency department-disease prevalence and willingness to return - Corrected Proof

David A. Jerrard, Rose M. Chasm — 2010-01-25

Abstract: Background: How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied. Objective: To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge. Methods: This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits. Results: A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6–71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9–91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7–82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6–33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5–64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9–25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8–8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician. Conclusion: Patients who leave the ED AMA have significant pathology.

Case Report: Aortoenteric Fistula Presenting as Repeated Hematochezia - Corrected Proof

Michael K. Doney, Gary M. Vilke — 2010-01-25

Abstract: Background: Aortoenteric fistula (AEF) is a rare but life-threatening condition in which expedient diagnosis is often difficult. It arises from erosion of a segment of aorta, usually an abdominal aortic aneurysm, into an adjacent portion of the gastrointestinal tract or between a vascular graft of the aorta and an adjacent portion of the gastrointestinal tract. It can present as life-threatening upper or lower gastrointestinal bleeding and is a surgical emergency that requires rapid assessment, emergency resuscitation, and definitive treatment. Case Report: To present the case of an 87-year-old man diagnosed with AEF in the emergency department. A review of the literature follows the case report. Conclusions: Aortoenteric fistula is a rare diagnosis that can cause sudden life-threatening gastrointestinal bleeding.

A New Maneuver for Endotracheal Tube Insertion during Difficult Glidescope Intubation - Corrected Proof

Ron M. Walls, M. Samuels-Kalow, A. Perkins — 2010-01-25

Abstract: Background: The GlideScope® Video Laryngoscope (Verathon, Bothell, WA) is a video laryngoscopy system that can be used for routine intubation, but is also commonly used as an alternative for difficult or failed airways. Previous reports have identified a very high incidence of grade 1 and grade 2 Cormack-Lehane glottic views, but despite these high-grade views, intubation is sometimes difficult due to the angle of insertion and shape of the endotracheal tube. Several maneuvers have been reported to increase the likelihood of successful endotracheal tube placement in these uncommon cases of failure. Case Report: We report the case of a patient who could not be intubated with the GlideScope® despite an easily obtained grade 1 laryngoscopic view. The impediment to intubation was identified as a sharp angulation of the trachea with respect to the larynx, such that the trachea formed a steep posterior angle with the laryngeal/glottic axis. Intubation was achieved using a previously unreported maneuver, in which the endotracheal tube with a sharply curved malleable stylet was inserted through the glottis, and then rotated 180° to permit passage down the trachea. Discussion and Conclusion: We believe that this maneuver may be useful in other cases of failed GlideScope® intubation, when a high-grade laryngeal view is obtained but tube passage is not possible due to a sharp posterior angulation of the trachea.

Firework-related injuries in Tehran's Persian Wednesday eve festival (Chaharshanbe Soori) - Corrected Proof

2010-01-25

Abstract: Background: Fireworks are the leading cause of injuries such as burns and amputations during the Persian Wednesday Eve Festival (Chaharshanbeh Soori). Objectives: This study was designed to explore the age of the high-risk population, the type of fireworks most frequently causing injury, the pattern of injury, and the frequency of permanent disabilities. Methods: This cohort study was performed by Tehran Emergency Medical Services at different medical centers all around Tehran, Iran, in individuals referred due to firework-related injuries during 1 month surrounding the festival in the year 2007. The following information was extracted from the patients' medical records: demographic data, the type of fireworks causing injury, the pattern and severity of the injury, the pre-hospital and hospital care provided for the patient, and the patient's condition at the time of discharge. In addition, information on the severity of the remaining disability was recorded 8 months after the injury. Results: There were 197 patients enrolled in the study with a mean age of 20.94 ± 11.31 years; the majority of them were male. Fuse-detonated noisemakers and homemade grenades were the most frequent causes of injury. Hand injury was reported in 39.8% of the cases. Amputation and long-term disability were found in 6 and 12 cases, respectively. None of the patients died during the study period. Conclusion: The fireworks used during a Chaharshanbe Soori ceremony were responsible for a considerable number of injuries to different parts of the body, and some of them led to permanent disabilities.

Further Confirmation of the Role of Clinical Acumen in Suspected Pulmonary Embolism - Corrected Proof

Oscar M.P. Jolobe — 2010-01-25

The outcome in the reported case of pulmonary embolism despite negative enzyme-linked immunosorbent assay D-dimer is a vindication of the role of clinical acumen in clinical decision-making (). Even in protocol-driven studies, there remains an important role for those clinicians who, in violation of the prescribed protocol, have sufficient courage of their convictions to give expression to their own clinical acumen. Such was the case in a prospective diagnostic management study that enrolled patients with clinically suspected pulmonary embolism (PE) in several hospitals in the Netherlands (). According to the protocol, where “the combination of PE being unlikely and a normal D-dimer test result ruled out PE,” both spiral computed tomography (CT) scanning and anticoagulant therapy were withheld. In that study, D-dimer test results and completed clinical probability assessments (using the criteria of Wells et al.) were available in 1632 patients (). Among those 1632 patients, there were 477 with the combination of unlikely clinical probability of PE and normal D-dimer, and in whom the protocol, by definition, mandated withholding spiral CT scanning. Nevertheless, in 2 of those patients, in violation of the protocol, the attending physician requested spiral CT scanning at baseline, and this investigation validated the clinical suspicion of PE. In 3 other patients with unlikely clinical probability of PE and negative D-dimer, PE occurred during the follow-up period. Among 86 patients with the combination of likely clinical probability of PE and normal D-dimer, PE was confirmed by baseline spiral CT scan in 7, and on follow-up in one other patient (). The results of this study validate the proposition that “clinical judgment continues to play a paramount role in patient care,” given the fact that, despite the introduction of new diagnostic tools and algorithms, during the period 1997–2006, in an institution with a 50.1% autopsy rate, the prevalence of misdiagnosis of fatal pulmonary embolism was second only to the prevalence of misdiagnosis of fatal myocardial infarction (). Accordingly, the most diagnostically advantageous way to optimize D-dimer test data might be to place greater reliance on likelihood ratios, as in the interpretation of serum ferritin results in suspected iron deficiency anemia, instead of dichotomizing the results into positive vs. negative (). The use of likelihood ratios to analyze data that have been presented in clinically sensible intervals also enhances the dialogue between clinically orientated researchers and their laboratory-based counterparts, so as to fine-tune diagnostic practice in the direction of better patient care.

Venous Air Embolism after Intravenous Contrast Administration for Computed Tomography - Corrected Proof

Kushaljit Singh Sodhi, Palash Jyoti Das, Pankaj Malhotra, Niranjan Khandelwal — 2010-01-25

A 65-year-old man with non-Hodgkin's lymphoma underwent contrast-enhanced computed tomography (CT) scan for routine follow-up. A CT scan of the neck, chest, and abdomen was performed with oral and intravenous contrast. Non-ionic intravenous contrast (100 mL) was injected with a power injector through the left antecubital vein, as is the protocol for all contrast-enhanced CT scans in our department. The CT scan revealed cervical, mediastinal, hilar, and abdominal lymphadenopathy. Air was seen in the left brachiocephalic vein and main pulmonary artery (). The patient was asymptomatic, however, and was discharged without any clinical evidence of embolic sequelae.

McKittrick-Wheelock Syndrome: A Rare Cause of Life-threatening Electrolyte Disturbances and Volume Depletion - Corrected Proof

Yu-Sung Lee, Hung-Jung Lin, Kuo-Tai Chen — 2010-01-25

Abstract: Background: It is uncommon for emergency physicians to discover a patient with circulatory failure resulting from chronic diarrhea. Objectives: We describe McKittrick-Wheelock syndrome, a rare disorder characterized by volume and electrolyte depletion and caused by colonic neoplasm. Case Report: The case of a 30-year-old woman who came to the Emergency Department with hypovolemic shock, hyponatremia, and hypokalemia with a background of chronic diarrhea is reported. The hypokalemia and dehydration were refractory to aggressive replacement therapy. Her condition was the result of fluid and electrolyte hypersecretion caused by a colonic adenocarcinoma and colonic polyposis. Surgical removal of the colon and subsequent volume and electrolyte replacement therapy resulted in complete recovery. Conclusion: This case is presented to increase awareness among emergency physicians of the rare disorder of McKittrick-Wheelock syndrome.

Portable Ultrasound for Remote Environments, Part II: Current Indications - Corrected Proof

Bret P. Nelson, Edward R. Melnick, James Li — 2010-01-25

Abstract: Background: With recent advances in ultrasound technology, it is now possible to deploy lightweight portable imaging devices in the field. Techniques and studies initially developed for hospital use have been extrapolated out of the hospital setting in a wide variety of environments in an effort to increase diagnostic accuracy in austere or prehospital environments. Objectives: This review summarizes current ultrasound applications used in out-of-hospital arenas and highlights existing evidence for such use. The diversity of applications and environments is organized by indication to better inform equipment selection as well as future directions for research and development. Discussion: Trauma evaluation, casualty triage, and assessment for pneumothorax, acute mountain sickness, and other applications have been studied by field medical teams. A wide range of outcomes have been reported, from alterations in patient care to determinations of accuracy compared to clinical judgment or other diagnostic modalities. Conclusions: The use of lightweight portable ultrasound shows great promise in augmenting clinical assessment for field medical operations. Although some studies of diagnostic accuracy exist in this setting, further research focused on clinically relevant outcomes data is needed.

Disaster 101: a novel approach to disaster medicine training for health professionals - Corrected Proof

Lancer A. Scott, Deborah S. Carson, I. Brian Greenwell — 2010-01-18

Abstract: Background: Despite efforts to improve preparedness training for health professionals, disaster medicine remains a peripheral component of traditional medical education in the United States (US) and is a rarely studied topic in the medical literature. Objectives: Using a pre-/post-test design, we measured the extent to which 4th-year medical students perceive, rapidly learn, and apply basic concepts of disaster medicine via a novel curriculum. Methods: Via a modified Delphi technique, an expert curriculum panel developed a 90-min didactic training scenario and two 40-min training exercises for medical students: a hazardous material scene and a surprise mass casualty incident (MCI) scenario with 100 life-sized mannequins. Medical students were quizzed before and after the didactic training scenario about their perceptions and their disaster medicine knowledge. Results: Students rated their overall knowledge as 3.76/10 pretest compared to 7.64/10 after the didactic program. Students' post-test scores improved by 54% and students participating in the MCI drill correctly tagged 94% of the victims in approximately 10 min. The average overall rating for the experience was 4.85/5. Conclusions: The results of this educational demonstration project reveal that students will value and can rapidly learn some core elements of disaster medicine via a novel addition to a medical school's curriculum. We believe the principle of a highly effective and well-received medical student course that can be easily added to a university curriculum has been demonstrated. Further research is needed to validate core competencies and performance-based education goals for US health professional trainees.

A Rare Case of Posterior Interosseous Nerve Palsy Associated With Radial Head Fracture - Corrected Proof

Karen D. Serrano, Gregory S. Rebella, Jason M. Sansone, Michael K. Kim — 2010-01-18

Abstract: Background: Radial head fractures are the most common fractures occurring about the elbow in adults, but there have been few reported cases of associated nerve injury. The little-known posterior interosseous nerve travels in close proximity to the radial head and is particularly susceptible to injury. Objectives: The objectives of this case report include raising awareness of the possibility of posterior interosseous nerve palsy after radial head fracture and reviewing the clinical assessment of the posterior interosseous nerve to exclude occult injury. Case Report: Here we report a case of a 21-year-old man who developed a posterior interosseous nerve palsy after a fracture of the radial head sustained during a wrestling match. He also sustained frostbite to the extremity due to overaggressive icing of the injury. Conclusions: Physicians should screen patients with radial head fractures for associated nerve injury. A thorough neurovascular examination with attention to the motor innervation patterns in the hand and wrist will help identify posterior interosseous nerve involvement. Careful discharge instructions will help prevent iatrogenic frostbite from overaggressive icing of injuries.

Trauma Activations and Their Effects on Non-trauma Patients - Corrected Proof

2010-01-18

Abstract: Background: Trauma patients consume many resources in the emergency department (ED), but what effect their care may have upon other patients seeking care is unclear. Objective: We sought to determine whether the presentation of trauma patients to the ED diverts staff and resources away from non-trauma patients. We hypothesized that the admission of trauma patients to the ED would result in longer times to physician evaluation and completion of laboratory and imaging studies, as well as a longer length of stay in the ED. Methods: This retrospective study reviewed and compared the charts of two groups of non-trauma ED patients. The group affected by trauma arrived up to 30 min after a trauma activation. The group unaffected by trauma arrived >3 h before or 3 h after a trauma activation. Times from arrival to initial MD evaluation, X-ray study, and computed tomography (CT) scan were documented. Median times from order to completion of laboratory results and imaging were compared, as well as total ED lengths of stay (LOS). Results: Median time from arrival to MD evaluation for patients affected by a trauma activation was almost twice as long as for unaffected patients (42 vs. 23 min, respectively; p < 0.001). Times from arrival to X-ray study, CT scan order, and laboratory results were all significantly greater for patients affected by a trauma activation (p < 0.001). For patients who required admission to the hospital, the affected group had a median LOS that was increased by 16 min (224 vs. 208 min, respectively) when compared to unaffected patients (p = 0.04). Conclusion: In the setting studied, the arrival of a trauma patient delayed physician evaluation and diagnostic testing. It only modestly increased the ED LOS for patients needing hospital admission.

Trauma and Substance Abuse: Deadly Consequences of Intravenous Percocet Tablets - Corrected Proof

Joseph M. Galante, Salman Ahmad, Elizabeth A. Albers, Matthew J. Sena — 2010-01-18

Abstract: Background: The prevalence of drug or alcohol addiction among trauma patients approaches 40%, yet many require narcotics during admission for adequate pain control. Provider awareness is the most reasonable option to avoid the devastating consequence of narcotic tablet injection. Objective: To illustrate the misuse of oral narcotics and to heighten provider awareness of a potential cause for acute respiratory failure in recently discharged patients. Case Report: A 20-year-old man was admitted to the hospital after an assault to the head and face. He was discharged from the hospital with 30 oral Percocet® (Endo Pharmaceuticals, Newark, DE) tablets after 24 h of observation. The day after discharge, emergency medical services were called to his residence for a decreased level of consciousness. During transport to the Emergency Department, he went into cardiac arrest with pulseless electrical activity. He could not be resuscitated. Postmortem biochemical and anatomical evidence suggested that the patient had attempted to inject crushed Percocet® tablets, which resulted in acute foreign body pulmonary microembolism and death. Conclusion: Patients with a history of substance abuse may be inclined to crush and inject oral narcotics. Narcotic injection should be considered in recently discharged patients who present with pulmonary failure. Patients with suspected narcotic addiction should be counseled before discharge on the risks of misusing oral medications in this fashion.

Changing spectrum of microbiology of liver abscess: Now Klebsiella, next Burkholderia pseudomallei - Corrected Proof

Vui Heng Chong — 2010-01-18

I read with interest the article by Pope et al. on Klebsiella spp.-related pyogenic liver abscess (PLA) and the threat this organism poses for emergency physicians in the West (). By and large, clinicians in the West are still relatively unfamiliar with infections caused by Klebsiella spp., including PLA. There are now increasing numbers of reports in the West (). Literature on Klebsiella spp.-related PLA has originated mostly from the East, where clinicians are more familiar with this infection. Klebsiella spp.-related sepsis typically occurs in patients with underlying disorders such as diabetes mellitus or other immune-compromising disorders. In Klebsiella-related PLA, it is not uncommon for patients to have multiple abscesses. In addition, metastatic infective foci are often reported (). Delay in diagnosis and appropriate treatment can lead to poor outcomes.

Evaluation of the Ventilatory Effects of a Restraint Chair on Human Subjects - Corrected Proof

2010-01-15

Abstract: Background: Combative individuals often require physical restraint in the prehospital and law enforcement setting. Specialized restraint chairs have been utilized for this purpose in the latter case, but concern has arisen that restrained individuals are at risk for ventilatory compromise and asphyxiation. Objective: We sought to determine if placement in a restraint chair results in alterations of respiratory or ventilatory function. Methods: We conducted a randomized, cross-over, controlled experimental trial in 10 healthy human volunteers performed at a university exercise physiology laboratory. After exercise on a cycle ergometer to 85% of the age-predicted maximal heart rate, subjects were randomized to either a sitting position or restraint chair with arms, legs, and chest secured using standard law enforcement protocol. Subjects remained in each position for 30 min, during which pulmonary function testing of maximal voluntary ventilation (MVV) was performed at 11 and 30 min. Arterial oxygen saturation (O2sat) and end-tidal PCO2 levels (PETCO2) were monitored continuously. Subjects repeated the experimental trial in the alternate position after a 45-min rest period. Measures between restraint and sitting positions were compared using a paired t-test at each time measurement. Results: There was no evidence of hypoxemia. Mean PETCO2 levels were not statistically different between the two groups at any time (p > 0.05), and there was no evidence of hypercapnia. Conclusion: In healthy subjects, placement in a restraint chair resulted in a small decrease in MVV, but did not result in any changes in O2sat or PETCO2.

Spinal Epidural Abscess - Corrected Proof

Marc Tompkins, Ian Panuncialman, Phillip Lucas, Mark Palumbo — 2010-01-11

Abstract: Background: Spinal epidural abscess is an uncommon disease with a relatively high rate of associated morbidity and mortality. The most important determinant of outcome is early diagnosis and initiation of appropriate treatment. Objectives: We aim to highlight the clinical manifestations, describe the early diagnostic evaluation, and outline the treatment principles for spinal epidural abscess in the adult. Discussion: Spinal epidural abscess should be suspected in the patient presenting with complaints of back pain or a neurologic deficit in conjunction with fever or an elevated erythrocyte sedimentation rate. Gadolinium-enhanced magnetic resonance imaging is the diagnostic modality of choice to confirm the presence and determine the location of the abscess. Emergent surgical decompression and debridement (with or without spinal stabilization) followed by long-term antimicrobial therapy remains the treatment of choice. In select cases, non-operative management can be cautiously considered when the risk of neurologic complications is determined to be low. Conclusion: Patients with a spinal epidural abscess often present first in the emergency department setting. It is imperative for the emergency physician to be familiar with the clinical features, diagnostic work-up, and basic management principles of spinal epidural abscess.

Abdominal palpation with OU MC manipulation (APOM) for women with acute abdomen caused by pelvic inflammatory disease: A pilot study - Corrected Proof

Ming-Cheh Ou, Chung-Chu Pang, Dennis Ou — 2010-01-04

Abdominal palpation is an important procedure for identifying the location of abdominal tenderness in women with an acute abdomen, and is used to narrow the differential diagnosis. However, the proximity of intra-abdominal organs can cause significant overlap of abdominal pain. The high frequency of gynecological diseases in women of childbearing age further complicates differentiation of the source of abdominal pain. Thus, routine lower abdominal palpation (LAP) has limited utility for excluding pelvic organ diseases in this setting. We report a manipulation to augment the routine LAP in diagnosing pelvic inflammatory disease (PID).

The Relationship of Radiocontrast, Iodine, and Seafood Allergies: A Medical Myth Exposed - Corrected Proof

Esteban Schabelman, Michael Witting — 2010-01-04

Abstract: Background: Radiocontrast agents are some of the most commonly used medications in the emergency department. However, both physicians and patients misunderstand the role that allergies play in reactions to radiocontrast media, especially with regards to shellfish and iodine. Objectives: We sought to review the literature describing rates of contrast reactions and risk of contrast administration to patients with iodine allergy, shellfish or seafood allergies, or prior reactions to intravenous iodinated contrast. Method: Both authors independently performed literature reviews, including position statements of stakeholder organizations, to gain perspective on important issues. They subsequently performed a systematic search for articles that estimated the risk of administration of iodinated contrast to those with a prior history of contrast reaction, “iodine allergy,” or reaction to seafood or shellfish. Results: The risk of reactions to contrast ranges from 0.2–17%, depending on the type of contrast used, the severity of reaction considered, and the prior history of any allergy. The risk of reaction in patients with a seafood allergy is similar to that in patients with other food allergies or asthma. A history of prior reaction to contrast increases the risk of mild reactions to as high as 7–17%, but has not been shown to increase the rate of severe reactions. Severe reactions occur in 0.02–0.5% and deaths in 0.0006–0.006%; neither have been related to “iodine allergy,” seafood allergy, or prior contrast reaction. Low-osmolality contrast media became available in 1988, and many of the higher risk estimates were from the era before it was widely available. Conclusions: Iodine is not an allergen. Atopy, in general, confers an increased risk of reaction to contrast administration, but the risk of contrast administration is low, even in patients with a history of “iodine allergy,” seafood allergy, or prior contrast reaction. Allergies to shellfish, in particular, do not increase the risk of reaction to intravenous contrast any more that of other allergies.

Human health hazards of veterinary medications: Information for emergency departments - Corrected Proof

Elaine Blythe Lust, Claudia Barthold, Mark A. Malesker, Tammy O. Wichman — 2010-01-04

Abstract: Background: There are over 5000 approved prescription and over-the-counter medications, as well as vaccines, with labeled indications for veterinary patients. Of these, there are several products that have significant human health hazards upon accidental or intentional exposure or ingestion in humans: carfentanil, clenbuterol (Ventipulmin), ketamine, tilmicosin (Micotil), testosterone/estradiol (Component E-H and Synovex H), dinoprost (Lutalyse/Prostamate), and cloprostenol (Estromate/EstroPlan). The hazards range from mild to life-threatening in terms of severity, and include bronchospasm, central nervous system stimulation, induction of miscarriage, and sudden death. Objective: To report medication descriptions, human toxicity information, and medical management for the emergent care of patients who may have had exposure to veterinary medications when they present to an emergency department (ED). Discussion: The intended use of this article is to inform and support ED personnel, drug information centers, and poison control centers on veterinary medication hazards. Conclusion: There is a need for increased awareness of the potential hazards of veterinary medications within human medicine circles. Timely reporting of veterinary medication hazards and their medical management may help to prepare the human medical community to deal with such exposures or abuses when time is of the essence.

“Cord Sign” in Deep Cerebral Venous Thrombosis - Corrected Proof

2010-01-04

A 17-month-old girl presented to the emergency department (ED) with an altered sensorium and abnormal limb movements that had developed over the prior 6 h. She had a history of vomiting (non-bilious and non-projectile), lethargy, and poor feeding for the prior 7 days. Neurological examination showed exaggerated limb reflexes, however, tone and power were normal. A non-contrast head computed tomography (CT) scan () showed ill-defined hypodensities in both thalami, with hyperdensity in the internal cerebral vein, vein of Galen, and straight sinus, suggestive of deep cerebral venous thrombosis (DCVT).

Ability of physicians to diagnose congestive heart failure based on chest X-ray - Corrected Proof

Sarah Kennedy, Barry Simon, Harrison J. Alter, Paul Cheung — 2010-01-04

Abstract: Background: Chest X-ray interpretation is an important skill in the diagnosis of congestive heart failure (CHF) by emergency physicians. Objectives: This study evaluated the ability of emergency physicians to recognize CHF on chest X-ray and the effect of level of training and confidence upon accuracy of interpretation. Methods: This was a prospective, blinded study in which 24 patients with an elevated brain natriuretic peptide, low ejection fraction, and diagnosis of CHF were retrospectively identified. In addition, 31 patients without CHF were identified and used as controls. These 55 chest X-rays were presented to emergency attendings and housestaff and a radiologist. We calculated the accuracy of the raters' diagnoses, and measured their confidence in that diagnosis and their level of training. Results: Physicians correctly identified the CHF chest X-rays 79% of the time (sensitivity 59%, specificity 96%; positive likelihood ratio 14.6, negative likelihood ratio 0.43). Accuracy ranged from a low of 78% among first-year residents to a high of 85% among attendings, and from 73% (confidence rating of 3/5) to 91% (confidence rating of 5/5). Increasing confidence was significantly correlated with accuracy across the spectrum (p = 0.001). An accuracy of 95% among radiologists suggests that a negative X-ray does not rule out CHF. Conclusions: High specificity (96%) and low sensitivity (59%) suggest that emergency physicians are excellent at identifying CHF on X-ray when present, but under-call it frequently. Sensitivity may be much higher in real life given clinical correlation. Both increased level of training and higher confidence significantly improved accuracy.

Encounters with venomous sea-life - Corrected Proof

Isaac Fernandez, Genaro Valladolid, Joseph Varon, George Sternbach — 2010-01-04

Abstract: Background: Sea-life with envenomation capabilities are quite abundant and diverse worldwide, being predominantly found in tropical waters. Most envenomations occur not as an attack, but as a result of self defense when the animal perceives danger; and often when locals or tourists are engaged in recreational activities. Most of these cases have only minor injuries, and few are fatal. Objectives: To describe the impact, clinical features, and management of life-threatening marine envenomations. Discussion: Recognition of the injury and identification of the responsible animal is crucial for quick and successful management. Medical professionals should be cognizant of presenting symptoms such as respiratory distress, muscle paralysis, or cardiovascular decompensation. For these patients, antivenom should be given immediately if available, followed by pharmacological and physical therapy to relieve symptoms and pain. If any foreign bodies are left at the site of the injury, they must be removed. Tetanus prophylaxis should also be considered in case of puncture, and if signs of early infection are present, broad-spectrum antibiotics should be administered. Conclusion: Management of envenomations from marine animals should be emphasized not only to health centers, but also to the general population, so that initial treatment can be started as soon as possible. Educational programs regarding risks and initial management for these incidents are also recommended to reduce the incidence and associated morbidity and mortality of the encounters.

Pseudoaneurysm of an arteriovenous dialysis graft - Corrected Proof

2010-01-04

A 44-year-old man with end-stage renal disease secondary to lupus nephritis presented to the Emergency Department (ED) 1 day after dialysis complaining of redness, swelling, and pain in his left forearm at the site of an arteriovenous graft.

Fistula formation to the bladder and to a corpus alienum as a rare complication of diverticulitis: A case report - Corrected Proof

Jefrey Vermeulen, Naomi van Hout, Rene Klaasen — 2009-12-28

Abstract: Background: Fistula formation is a known complication of diverticulitis. Treatment of a diverticular fistula depends on the comorbidity of the patient and the severity of the disease. Case report: A 59-year-old man presented to the Emergency Department with chronic lower back pain that was being treated with a neurostimulator. He presented with severe sepsis, and an abscess formation near the neurostimulator. An abdominal and pelvic computed tomography scan revealed diverticulitis complicated by fistula formation to the neurostimulator and bladder. He was successfully treated by a two-stage procedure: first, exploration and drainage of the abscess, with removal of the foreign body, followed by a sigmoid resection 1 week later. Conclusion: In rare but severe presentations of diverticular disease, it is very important to limit initial treatment to the most threatening disorder.

Corrected Proof

Larry D. Pham, Michael D. Burg — 2009-12-28

In emergency medicine, efficiency is golden. An evidence-based and focused clinical examination is critical because we cannot spend precious time performing a complete history and physical examination. We need to use our time with patients wisely and yet still establish the most accurate diagnoses possible. It is essential that we know which items from the history and physical are useful and which are not. What questions should we ask based on the patient's presentation? Which physical examination maneuvers are important? How do we interpret signs and symptoms in making a diagnosis or ruling out a disease? And finally, which basic studies and quick laboratory tests are most clinically relevant? Answers to these questions are vital to us to increase efficiency in the always fast-paced emergency department (ED).

Adult-onset of mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (melas) syndrome presenting as acute meningoencephalitis: a case report - Corrected Proof

2009-12-28

Abstract: Background: Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome is a rare mitochondrial disorder with a wide range of multisystemic symptoms. Epileptic seizures are common features of both MELAS and meningoencephalitis and are typically treated with anticonvulsants. Objectives: To provide the reader with a better understanding of MELAS and the adverse effects of valproic acid. Case Report: A 47-year-old man with a history of diabetes, hearing loss, sinusitis, and otitis media was brought to our emergency department due to acute onset of fever, headache, generalized seizure, and agitation. Because acute meningoencephalitis was suspected, the patient was treated with antibiotics on an empirical basis. The seizure activity was aggravated by valproic acid and abated after its discontinuation. MELAS was suspected and the diagnosis was confirmed by the presence of a nucleotide 3243 A→G mutation in the mitochondrial DNA. Conclusion: Detailed history-taking and systematic review help emergency physicians differentiate MELAS from meningoencephalitis in patients with the common presentation of epileptic seizures. Use of valproic acid to treat epilepsy in patients suspected of having mitochondrial disease should be avoided. Underlying mitochondrial disease should be suspected if seizure activity worsens with valproic acid therapy.

Emergency Calls for Swine Flu: How to Deal with Nuisance Calls? - Corrected Proof

Viroj Wiwanitkit — 2009-12-28

Swine flu has become a great threat to the public in several countries. In Thailand, swine flu is pandemic, and an emergency telephone line for swine flu, “1422,” has been instituted. I would like to discuss a problem encountered on this emergency telephone line.

Spontaneous lumbar artery pseudoaneurysm bleeding: a case report - Corrected Proof

Pin Liu, Te-Fa Chiu, Chih-Huang Li — 2009-12-23

A 47-year-old man presented to our emergency department in distress. Upon arrival, he had a pulse of 102 beats/min, respiratory rate of 18 breaths/min, and blood pressure of 87/53 mm Hg. He complained of persistent severe right flank pain with skin bruising. The dull pain started abruptly while he was at rest about 2 days prior. He denied any history of surgery and recalled no trauma during the previous month. He had no gross hematuria and the stool was not tarry or bloody. His only noticeable medical disease was alcoholic liver cirrhosis. On physical examination, he had pale conjunctivae. There was a large area of ecchymosis, swelling, and tenderness extending from the right flank to the lower back and buttock to the right upper thigh (). The hemoglobin was 8.2 g/dL and platelet count 31,000/μL, and the international normalized ratio for prothrombin time was 1.5.