The Journal of Emergency Medicine - Articles in Press

Right Atrial Thrombus Secondary to Pacemaker Wires - Corrected Proof

Alexander C. Feuchter, Kenneth D. Katz — 2010-07-26

Abstract: Background: Pacemaker-induced right atrial thrombus is a rare condition that has not been described in the Emergency Medicine literature. This is a potentially fatal condition that is diagnosed with an echocardiogram and treated with surgical removal, thrombolytics, or long-term anticoagulation.Objectives: This case report is designed to increase awareness among emergency physicians of this potentially fatal condition.Case Report: We describe the case of a patient with a massive right atrial thrombus secondary to pacemaker wire who presented to the Emergency Department with syncope, bradycardia, and rapid hemodynamic deterioration.Conclusion: Emergency physicians should be aware of this life-threatening entity. Emergency bedside cardiac ultrasound or echocardiogram may be of value in its early identification.

Fleischner’s Sign in a Massive Pulmonary Embolism - Corrected Proof

Timothy Cooksley, Belkys Husein, Javaid Iqbal, John Bright — 2010-07-26

A 44-year-old woman presented to the Emergency Department with right-sided pleuritic chest pain and dyspnea. She had a history of asthma, which was controlled with Seretide (fluticasone/salmeterol combination; GlaxoSmithKline, Brentford, Middlesex, UK) and albuterol inhalers. She was a non-smoker and had no significant risk factors for the development of thromboembolism.

Severe Iron Deficiency Anemia and Lice Infestation - Corrected Proof

David A. Guss, Mark Koenig, Edward M. Castillo — 2010-07-26

Abstract: Background: Lice infestation is a commonly encountered disorder in emergency medicine. The louse survives from a blood meal from its host; hence, iron deficiency anemia is a theoretic possibility. A limited number of reports of severe iron deficiency anemia have appeared in the veterinary literature, but a thorough review of the medical literature did not reveal a single instance in human beings.Objective: We report a small case series of patients with heavy louse infestation and profound iron deficiency anemia.Case report: The index case along with two other cases discovered from an exhaustive search of 4 years of the institution’s Emergency Department records all had heavy infestation with head and body lice. Laboratory evaluation revealed serum hemoglobin levels under 6 gm/dL, low serum ferritin levels, and microcytic red blood cell indices. All patients were admitted to the hospital, received transfusions, and had evaluation of their anemia. No patient had evidence of gastrointestinal blood loss or alternative explanation for their anemia.Conclusions: Although cause and effect cannot be established from this case series, to the best of our knowledge, this is the first published evidence of a provocative association of louse infestation and severe iron deficiency anemia in humans.

Serious Infectious Complications Related to Extremity Cast/Splint Placement in Children - Corrected Proof

B. Elizabeth Delasobera, Rick Place, John Howell, Jonathan E. Davis — 2010-07-26

Abstract: Background: Extremity injuries necessitating splinting or casting are commonly seen in the emergency department (ED) setting. Subsequently, it is not uncommon for patients to present to the ED with complaints related to an extremity cast or splint.Objective: To present a literature-based approach to the identification and initial management of patients with possible infectious cast/splint complications in the ED setting.Case Reports: We present two cases of serious infectious complications arising from extremity cast/splint placement seen in a single pediatric ED: a case of toxic shock syndrome in an 8-year-old child, and a case of necrotizing fasciitis resulting in upper extremity amputation in a 3-year-old child.Conclusions/Summary: A wide spectrum of potential extremity cast/splint infectious complications may be seen, which include limb- or life-threatening infections such as toxic shock syndrome and necrotizing fasciitis. Simply considering these diagnoses, and removing the cast or splint to carefully inspect the affected extremity, are potential keys to early identification and optimal outcome of cast/splint complications. It is also prudent to maintain particular vigilance when treating a patient with a water-exposed cast, which may lead to moist padding, skin breakdown, and potential infection. In patients with suspected serious infections, aggressive fluid management and antibiotic therapy should be initiated and appropriate surgical consultation obtained without delay.

Medications from the Web: Use of Online Pharmacies by Emergency Department Patients - Corrected Proof

2010-07-26

Abstract: Background: Internet access and online pharmacies are a resource for purchasing medications. It is unclear if this venue is being used by emergency department (ED) patients to obtain medications.Objective: We sought to determine the frequency of and to characterize online pharmacy use by ED patients. We hypothesized that students and younger patients would be more likely than others to obtain medications via online pharmacies due to their familiarity with the Internet.Methods: This prospective, cross-sectional survey occurred in an urban university ED. We enrolled a convenience sample of adult patients. The study was Institutional Review Board approved, and informed consent was obtained. To determine differences between online pharmacy users and non-users, chi-squared or Fisher’s exact tests were used for categorical data, and t-test or Wilcoxon rank sum tests were used for continuous variables.Results: There were 1657 patients who completed the survey. The mean age was 39 years, standard deviation 16 years; 947/1657 (57%) reported awareness of online pharmacies; 89/1657 (5.4%) patients used the Internet to order medications. More patients with prescription plans ordered medications from online pharmacies (94.3% vs. 70%; p<0.0001), and Internet users were more commonly on multiple medications (median 3 vs. 1; p<0.0001). There was no difference in age (39.4 vs. 41 years; p=0.2) or student status (13.8% vs. 14.9%; p=0.8) between the two groups.Conclusions: Approximately 5% of ED patients used the Internet to obtain medications. Contrary to our hypothesis, younger patients were not more likely to use the Internet for medications. Patients on multiple medications and those with prescription plans used online pharmacies more frequently.

Acute Confusion in Dialysis Patients - Corrected Proof

Hyun Ho Ryu, Hyun Lee Kim — 2010-07-26

To the Editor: We read with interest the recent case by Martinez-Diaz and Hsia . The adverse effects induced by acyclovir can present as neurotoxic or psychiatric complications. Symptoms of this drug vary from insomnia or irritability to acute confusion or hallucinations . Neurotoxicity by acyclovir results from an accumulation of the antiviral and its metabolites in the bloodstream. We experienced a similar case of acute confusion in a dialysis patient.

Letter to the Editor Re: Removal of Steel Penile Constriction Ring - Corrected Proof

Stella Yiu — 2010-07-26

To the Editor: I read with great interest the practical article by Peay et al. concerning the removal of a hardened steel penile constriction ring in the Emergency Department (ED) . I had witnessed a similar case in the past in which the patient waited for several hours before presentation. Similar to the case in the article, neither the ED ring cutter nor the Fire Department bolt cutter was suitable.

Lamotrigine-associated Thrombocytopenia and Leukopenia - Corrected Proof

Mesut Okur, Avni Kaya, Hüseyin Çaksen, Gökmen Taşkın — 2010-07-26

To the Editor: Lamotrigine (LTG), a wide-spectrum antiepileptic drug, is derived from the dihydrofolate reductase inhibitor class of compounds and is thought to act mainly through blocking the influx of sodium ions, thereby reducing excess glutamate release and stabilizing neuronal membranes . It is effective as an adjunctive treatment of refractory partial seizures and idiopathic generalized epilepsy in adults and children . Rash has been reported as the most frequent side effect of LTG, whereas blood dyscrasias have been noted rarely . We report a boy who developed thrombocytopenia and leukopenia after receiving LTG for epilepsy.

Acute Central Nervous System Depression after Subcutaneous Use of Prilocaine in an Infant - Corrected Proof

Hamza Karabiber, M. Ayse Selimoglu, Melek Cetin, Serap Tekin, Sibel Gurbuz — 2010-07-26

To the Editor: Prilocaine hydrochloride (HCl) is usually used as a local anesthetic for minor procedures such as liver biopsy. Potential adverse effects of that local anesthetic include methemoglobin formation and cardiac dysrhythmia, which are frequently reported in the literature. Central nervous system (CNS) disturbances, respiratory depression, and cardiovascular collapse have so far been very rarely reported.

Pseudomonas Arthritis in an Elderly Woman - Corrected Proof

Enrique Antón — 2010-07-26

To the Editor: A 76-year-old woman presented to the Emergency Department with a 2-week history of pain and swelling of the first metatarsal joint in the right foot. Fever and systemic features were absent. Medical therapy had not been effective. She was hypertensive. No history of previous infection or antibiotic therapy was reported.

Why Go Blind When You Can See? - Corrected Proof

Adrian A. Matioc, Harald V. Genzwuerker — 2010-07-26

To the Editor: We read with interest the article by Lutes and Worman about the failure of the disposable King laryngeal tube (KLT-D, King Systems, Noblesville, IN) to act as a conduit to the trachea for a gum elastic bougie . This finding is consistent with the lack of predictable continuum between the (non-intubating) Classic laryngeal mask airway (LMA North America, San Diego, CA) and the glottic opening. A blind insertion attempt with a suction catheter will most likely not penetrate the trachea, and rescue medication administered through a non-intubating supraglottic airway (SGA) will not reach the trachea consistently . Even with the LMA-Fastrach (LMA North America) designed for blind intubation, success rate for first attempt was only 79.8% in a large analysis . Nevertheless, as a rescue device, the KLT-D should function as a “dedicated” airway: used emergently for oxygenation and converted in controlled conditions to an endotracheal tube (ETT) .

A Wakeup Call to The Food and Drug Administration to Ban Cornstarch on Medical Gloves - Corrected Proof

2010-07-26

To the Editor: During the last 30 years, scientific, experimental, and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic throughout the world . Realizing the dangers of cornstarch on examination and surgical gloves, Germany’s regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1977 . In 2000, the Purchasing and Supply Agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch .

Meningococcal Epiglottitis in a Diabetic Adult Patient: A Case Report - Corrected Proof

Derek Kuhl Richardson, Trina Helderman, Paris Lovett — 2010-07-23

Abstract: Background: After deployment of the Haemophilus influenzae vaccination, the range of pathogens causing acute epiglottitis has changed, as has the epidemiology from a primarily pediatric syndrome towards more frequent adult onset.Objectives: We present a case of acute-onset meningococcal epiglottitis in an adult patient, to our knowledge one of a few reported cases in the medical literature. We review the historic changes and outcomes of similar episodes.Case Report: A 37-year-old diabetic man presented to our Emergency Department in acute respiratory distress. Examination revealed epiglottitis; his airway subsequently closed rapidly and was secured by surgical cricothyroidotomy; blood cultures showed the primary pathogen to be Neisseria meningitidis type C.Conclusion: Neisseria meningitidis has been found to be an emerging cause of acute epiglottitis in adult patients over the last decade, possibly having worsened outcomes compared to other etiologies.

Sensitivity of Erythrocyte Sedimentation Rate and C-reactive Protein for the Exclusion of Septic Arthritis in Emergency Department Patients - Corrected Proof

Praveen Hariharan, Christopher Kabrhel — 2010-07-23

Abstract: Background: Previous studies in post-operative orthopedic and pediatric patients suggest that erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) testing may be helpful in ruling out septic arthritis. However, these tests have not been evaluated in a population of adult Emergency Department (ED) patients.Study Objective: Determine the sensitivity of ESR and CRP in patients with septic arthritis.Methods: Retrospective analysis of ED patients with septic arthritis from 2003 to 2008. Eligible patients had an International Classification of Diseases-Ninth Revision diagnosis of pyogenic arthritis (711.0x) plus: positive synovial fluid culture, positive synovial Gram stain, or operative irrigation. Patients were excluded if no ESR or CRP was performed within 24h. Sensitivity of ESR and CRP at various cutoffs was calculated with 95% confidence intervals (CI).Results: We identified 167 patients with septic arthritis. We included 143 (86%) who had ESR (n=140, 84%) or CRP (n=96, 57%) performed. Mean age was 49 (± 22) years, and 85 (59%) were male. Race was: 125 (87%) white, 4 (3%) black, and 12 (8%) Hispanic. Thirty-five (24%) had infection of prosthetic joints. Synovial cultures were positive in 102 (71%). Sensitivity of ESR was: 98% (95% CI 94–100%) using a cutoff of≥10mm/h (n=134) and 94% (95% CI 88–97%) using a cutoff of≥15mm/h (n=131). The sensitivity of CRP was 92% (95% CI 84–96%) using a cutoff of≥20mg/L (n=88).Conclusion: ESR and CRP have sensitivities of>90% for septic arthritis, but only when low thresholds are used. Further study is required to determine the clinical usefulness of ESR and CRP testing.

Endowed Faculty Positions in Academic Emergency Medicine: 5 Years Later - Corrected Proof

Alicia S. Devine, Francis L. Counselman — 2010-07-23

Abstract: Background: In 2004, we examined the number of endowed faculty positions (both chair and professorship) in Academic Departments of Emergency Medicine (ADEMs) in the United States (US).Objective: To survey ADEMs in the United States concerning their number of endowed faculty positions and compare the results to the 2004 study.Methods: A survey was sent to the chairs of all ADEMs in the United States belonging to the Association of Academic Chairs of Emergency Medicine. We requested information on: number of endowed chair and professorship positions, amount required to fund, date established, source of funding, and future plans.Results: Seventy-three chairs responded, for a 100% response rate. Eight chairs reported one endowed chair position each. One chair reported two such positions and one chair reported three chair positions. In total, 10 ADEMs (13.7%) reported 13 endowed chair positions. For endowed professorships, eight chairs reported one professorship each and two chairs reported two such positions. A total of 10 ADEMs (13.7%) reported having 12 endowed professorships. In all, 19 ADEMs (26%) reported a total of 25 such positions. The typical amount allowed to spend was 4–5% of the value of the endowment annually. The average amount necessary to fund an endowed chair position was $1.5 million, and $1 million for an endowed professorship.Conclusion: Twenty-six percent of all US ADEMs now have an endowed faculty position. There has been a nearly threefold increase in the number of endowed faculty positions over the past 5 years.

An Impedance Threshold Device Increases Blood Pressure in Hypotensive Patients - Corrected Proof

2010-07-16

Abstract: Background: The impedance threshold device (ITD-7) augments the vacuum created in the thorax with each inspiration, thereby enhancing blood flow from the extrathoracic venous systems into the heart.Objectives: To the best of our knowledge, the ITD-7 has not previously been investigated in hypotensive patients in the emergency department (ED) or the prehospital setting. The objective of this study was to determine whether the ITD-7 would increase systolic arterial pressures in hypotensive spontaneously breathing patients.Methods: The ED study was a prospective, randomized, double-blind, sham control design. Patients with a systolic blood pressure ≤ 95 mm Hg were randomized to breathe for 10 min through an active or sham ITD. The primary endpoint was the change in systolic blood pressure measured non-invasively. The prehospital study was a prospective, non-blinded evaluation of the ITD-7 in hypotensive patients.Results: In the ED study, the mean ± standard deviation rise in systolic blood pressure was 12.9 ± 8.5 mm Hg for patients (n = 16) treated with an active ITD-7 vs. 5.9 ± 5.9 mm Hg for patients (n = 18) treated with a sham ITD-7 (p < 0.01). In the prehospital study, the mean systolic blood pressure before the ITD-7 was 79.4 ± 10.2 mm Hg and 107.3 ± 17.6 mm Hg during ITD-7 use (n = 47 patients) (p < 0.01).Conclusion: During this clinical evaluation of the ITD-7 for the treatment of hypotensive patients in the ED and in the prehospital setting, use of the device significantly increased systolic blood pressure and was safe and generally well tolerated.

Ptosis as the Initial Presentation of Guillain-Barré Syndrome - Corrected Proof

Hao-Wen Teng, Jia-Ying Sung — 2010-07-16

Abstract: Background: Guillain-Barré syndrome has been regarded as a spectrum of diseases with many variants.Objective: To present a case in which, when the ocular muscles are affected in the beginning, it is very challenging to distinguish Guillain-Barré syndrome from myasthenia gravis.Case Report: We describe a patient with Guillain-Barré syndrome who presented initially with isolated ptosis without ophthalmoplegia and subsequently developed descending paralysis. Due to the primary involvement of the lid levators, the patient was initially diagnosed as having a myasthenic crisis.Conclusion: Although extremely rare, Guillain-Barré syndrome can present initially as isolated ptosis with subsequent descending paralysis.

Managing Emergency Department Patients with Recent-onset Atrial Fibrillation - Corrected Proof

David R. Vinson, Ted Hoehn, David J. Graber, Terry M. Williams — 2010-07-16

Abstract: Background: The management of emergency department (ED) patients with presumed recent-onset atrial fibrillation or flutter≤48h in duration varies widely.Objective and Method: We conducted a prospective study across three affiliated community EDs within a large integrated health care delivery system to describe the management of patients with recent-onset atrial fibrillation or flutter, to determine the safety and effectiveness of ED cardioversion, and to measure the incidence of thromboembolism 30 days after discharge.Results: We enrolled 206 patients with convenience sampling between June 2005 and November 2007. Mean age was 64.0±14.4 years (range 21–96 years). Patients were grouped for analysis into four categories based on whether cardioversion was 1) spontaneous in the ED (59; 28.6%); 2) attempted with electrical or pharmacological means (115; 56.3%), with success in 110 (95.7%); 3) hoped for during a short stint of home observation (16; 7.8%, 11 of which spontaneously converted to sinus rhythm within 24h); or 4) contraindicated (16; 7.8%). Of the entire group, 183 (88.8%) patients were discharged home. Adverse events requiring ED interventions were reported in 6 (2.9%; 95% confidence interval [CI] 1.1–6.2%) patients, all of whom recovered. Two (1.0%; 95% CI 0.1–3.5%) patients were found to have an embolic event on 30-day follow-up.Conclusions: Our approach to ED patients with presumed recent-onset atrial fibrillation or flutter seems to be safe and effective, with a high rate of cardioversion and discharge to home coupled with a low ED adverse event and 30-day thromboembolic event rate.

Rescuer Fatigue in the Elderly: Standard vs. Hands-only CPR - Corrected Proof

Joseph W. Heidenreich, Aleta Bonner, Arthur B. Sanders — 2010-07-16

Abstract: Background: Hands-only cardiopulmonary resuscitation (HO-CPR) is recommended as an alternative to standard CPR (STD-CPR). Studies have shown a degradation of adequate compressions with HO-CPR after 2min when performed by young, healthy medical students. Elderly rescuers' ability to maintain an adequate compression rate and depth until emergency medical services (EMS) arrives is unknown.Objectives: The specific aim of this study was to compare elderly rescuers' ability to maintain adequate compression rate and depth during HO-CPR and STD-CPR in a manikin model.Methods: In this prospective, randomized crossover study, 17 elderly volunteers performed both HO-CPR and STD-CPR, separated by at least 2 days, on a manikin model for 9min each. The primary endpoint was the number of adequate chest compressions (> 38mm) delivered per minute. Secondary endpoints were total compressions, compression rate, and the number of breaks taken for rest.Results: There was no difference in the number of adequate compressions between groups in the first minute; however, the STD-CPR group delivered significantly more adequate chest compressions in minutes 2–9 (p<0.05). The total number of compressions delivered was significantly greater in the HO-CPR than STD-CPR group when considering the entire resuscitation period. A significantly greater number of rescuers took breaks for rest during HO-CPR than STD-CPR.Conclusions: Although HO-CPR resulted in a greater number of overall compressions than STD-CPR, STD-CPR resulted in a greater number of adequate compressions in all but the first minute of resuscitation.

Acute Myocardial Infarction Presenting with Pharyngeal Pain Alone - Corrected Proof

2010-07-16

Abstract: Background: Pharyngeal pain alone due to acute myocardial infarction is rare.Case Report: A 37-year-old man felt sudden pharyngeal pain. He was transferred to a medical facility under a misdiagnosis of pharyngitis. However, he was thereafter found to have acute myocardial infarction and thus was transferred to another hospital. An emergency coronary angiogram revealed complete occlusion of the right coronary artery and he underwent coronary angioplasty. The patient was later discharged ambulatory.Conclusion: A misdiagnosis of acute myocardial infarction can lead to unfavorable outcomes; therefore, physicians or emergency medical technicians should be aware of this disease even when a patient complains of sudden pharyngeal pain alone.

Prolonged Coma in a Child Due to Hashish Ingestion with Quantitation of THC Metabolites in Urine - Corrected Proof

Shaun D. Carstairs, Michael K. Fujinaka, Grant E. Keeney, Binh T. Ly — 2010-07-16

Abstract: Background: Cannabinoid-containing substances are commonly abused worldwide. Significant toxicity from these substances is uncommon in adults but can result in significant symptoms in children; these symptoms are usually short-lived.Objectives: To report a case of prolonged mental status alteration of more than 2 days in a child who ingested hashish.Case Report: A 14-month-old child presented comatose to a pediatric emergency department after ingestion of hashish; she did not regain consciousness for more than 48h. Quantitative testing of the child’s urine for a tetrahydrocannabinol metabolite revealed a markedly elevated level, the decline of which coincided with the child’s clinical improvement.Conclusions: Significant ingestion of cannabinoid-containing substances is capable of causing prolonged symptoms (including coma) in children.

Duty Hours in Emergency Medicine: Balancing Patient Safety, Resident Wellness, and the Resident Training Experience: A Consensus Response to the 2008 Institute of Medicine Resident Duty Hours Recommendations - Corrected Proof

2010-07-16

Abstract: Background: Representatives of emergency medicine (EM) were asked to develop a consensus report that provided a review of the past and potential future effects of duty hour requirements for EM residency training. In addition to the restrictions made in 2003 by the Accreditation Council for Graduate Medical Education, the potential effects of the 2008 Institute of Medicine (IOM) report on resident duty hours were postulated.Discussion: The elements highlighted include patient safety, resident wellness, and the resident training experience. Many of the changes and recommendations did not affect EM as significantly as other specialties. Current training standards in EM have already emphasized patient safety by requiring continuous onsite supervision of residents. Resident fatigue has been addressed with restrictions of shift lengths and limitation of consecutive days worked.Conclusion: One recommendation from the IOM was a required 5-h rest period for residents on call. Emergency department (ED) patient safety becomes an important concern with the decrease in the availability and in the patient load of a resident consultant that may result from this recommendation. Of greater concern is the already observed slower throughput time for admitted patients waiting for resident care, which will increase ED crowding and decrease patient safety in academic institutions. A balance between being overly prescriptive with duty hour restrictions and trying to improve resident wellness was recommended. Discussion is included regarding the appropriate length of EM training programs if clinical experiences were limited by new duty hour regulations. Finally, this report presents a review of the financing issues associated with any changes.

The Future of Emergency Medicine - Corrected Proof

2010-07-16

Abstract: Background: The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care.Summary: In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to—and will continue to contribute to—a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EM's future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

Acute Hydrocephalus Secondary to Neurocysticercosis - Corrected Proof

Drew Weber, E. Andrew Stevens, Daniel E. Couture, James E. Winslow — 2010-07-15

A 43-year-old man was brought to the Emergency Department (ED) by his family for worsening headache and confusion. His only medical problems were hypertension and diabetes; he had no prior history of headaches. Due to the abrupt onset of symptoms over the previous 2 h, an emergent computed tomography (CT) non-contrast head scan was ordered and revealed a dense lesion at the cerebral aqueduct with resulting hydrocephalus (). Shortly after the CT scan, he developed emesis and mental status deterioration (Glasgow Coma Scale score went from 14 to 7), necessitating intubation.

A Porcine Training Model for Ultrasound Diagnosis of Pneumothoraces - Corrected Proof

Amy J. Bloch, Scott A. Bloch, Lalainia Secreti, N. Heramba Prasad — 2010-07-12

Abstract: Background: Ultrasound for the evaluation of pneumothoraces has been extensively studied. Several medical specialties have recognized the benefit of this technique; however, a training model has not been established.Objective: Using a porcine model, we attempt to establish a model for the training of ultrasound diagnosis of pneumothoraces.Methods: Two pigs were anesthetized on two separate occasions. A pneumothorax was introduced each time. Participants were blinded to the study design and were not aware of the number of pneumothoraces present. A brief training lecture was given before performing the ultrasound, and the results of each lung examination were recorded. The data were collected and analyzed for the accuracy of assessment.Results: A total of 18 individuals participated in the study, with six individuals participating on both days. Ninety-six lung ultrasound examinations were completed; 69% of the lung examinations were correctly diagnosed on the first day and 94% on the second. Participants correctly diagnosed a pneumothorax 50% of the time at the first laboratory and 100% of the time at the second. Participants who attended both laboratories increased their ability to diagnose a pneumothorax from 66% to 100%.Conclusion: We believe this porcine model can be used for the training of ultrasound diagnosis of pneumothoraces. Participants who completed two training sessions improved their accuracy from 66% to 100% in the diagnosis of pneumothoraces. Study participants rated the educational experience highly on a post-laboratory questionnaire, and feel they will be more comfortable using it in a real-life situation.

Implementation of an Emergency Department Computer System: Design Features That Users Value - Corrected Proof

Nicholas J. Batley, Hibah O. Osman, Amin A. Kazzi, Khaled M. Musallam — 2010-07-12

Abstract: Background: Electronic medical records (EMRs) can potentially improve the efficiency and effectiveness of patient care, especially in the emergency department (ED) setting. Multiple barriers to implementation of EMR have been described. One important barrier is physician resistance. The “ED Dashboard” is an EMR developed in a busy tertiary care hospital ED. Its implementation was exceptionally smooth and successful.Study Objectives: We set out to examine the design features used in the development of the system and assess which of these features played an important role in the successful implementation of the ED Dashboard.Methods: An anonymous survey of users of the ED Dashboard was conducted in January and February 2009 to evaluate their perceptions of the degree of success of the implementation and the importance of the design features used in that success. Results were analyzed using SPSS software (SPSS Inc., Chicago, IL).Results: Of the 188 end-users approached, 175 (93%) completed the survey. Despite minimal training in the use of the system, 163 (93%) perceived the system as easy or extremely easy to use. Users agreed that the design features employed were important contributors to the system's success. Being alerted when new test results were ready, the use of “most common” lists, and the use of color were features that were considered valuable to users.Conclusion: Success of a medical information system in a busy ED is, in part, dependent on careful attention to subtle details of system design.

Abdominal Pain in a Postpartum Patient - Corrected Proof

Muhammad Waseem, Homer Cunningham-Deshong, Joel Gernsheimer — 2010-07-12

Abstract: Background: Acute abdominal pain is a very common presenting complaint in the Emergency Department (ED). Making the correct diagnosis may be very complicated and difficult. It is even more difficult and complicated in the postpartum period, because other less common but important diagnoses must be considered. One of these potentially life-threatening diagnoses for which patients should be evaluated is uterine rupture.Objectives: To discuss uncommon, but important, causes of abdominal pain that may occur in the postpartum period. To learn the clinical presentation, risk factors, evaluation, and management of uterine rupture in the postpartum patient.Case Report: We present the case of a 36-year-old woman who presented to the ED with 2 days of abdominal pain and fever. The patient had had a caesarian section (C-section) 2 weeks before this admission. This was her fourth C-section. On examination, she had right lower quadrant tenderness. A computed tomography scan of the abdomen with contrast was obtained and it revealed uterine perforation with an adjacent abscess. The patient received intravenous fluids and broad-spectrum antibiotics. A laparotomy was performed that confirmed the diagnosis of uterine perforation. The patient subsequently did very well.Conclusions: Uterine perforation should be considered in any postpartum patient that presents with acute abdominal pain, especially if there are risk factors, such as previous C-sections. Appropriate evaluation, consultations, and management should be done expeditiously to avoid increased morbidity and mortality.

Back to the Bedside: The 8-year Evolution of a Resident-as-Teacher Rotation - Corrected Proof

2010-07-12

Abstract: Background: Teaching our residents to teach is a vital responsibility of Emergency Medicine (EM) residency programs. As emergency department (ED) overcrowding may limit the ability of attending physicians to provide bedside instruction, senior residents are increasingly asked to assume this role for more junior trainees. Unfortunately, a recent survey suggests that only 55% of all residencies provide instruction in effective teaching methods. Without modeling from attending physicians, many residents struggle with this responsibility.Objectives: We introduced a “Resident-as-Teacher” curriculum in 2002 as a means to address a decline in bedside instruction and provide our senior residents with a background in effective teaching methods.Discussion: Here, we describe the evolution of this resident-as-teacher rotation, outline its current structure, cite potential pitfalls and solutions, and discuss the unique addition of a teach-the-teacher curriculum.Conclusion: A resident-as-teacher rotation has evolved into a meaningful addition to our senior residents' training, fostering their growth as educators and addressing our need for bedside instruction.

An Unusual Case of Otorrhagia - Corrected Proof

Susanne J. Spano, Michael D. Burg — 2010-07-09

A 64-year-old man presented to the Emergency Department complaining of headache and bilateral ear pain after falling face first during a syncopal episode. He denied nausea, vomiting, or focal neurological complaints, and was alert and oriented, with blood-tinged fluid—which formed “halos” on the bed sheets—draining from both ears. A brain computed tomography (CT) scan with axial and coronal views was performed due to a concern for basilar skull fracture and was read as negative by the on-duty radiologist (). However, review of the study by the emergency physicians/case authors demonstrated bilateral comminuted fractures and dislocations of the mandibular condyles (). The patient was admitted to the Oromaxillofacial Surgery service for repair of his injuries and was discharged the following morning. No basilar skull fracture was identified. The patient was well at 30-day follow-up.

An Unusual Cause of Pelvic Pain and Fever: Periurethral Abscess from an Infected Urethral Diverticulum - Corrected Proof

Jack M. Butler, Derek Bennetsen, Augusto Dias — 2010-07-08

Abstract: Background: The evaluation of patients with pelvic pain is a common task for emergency physicians. Accurate diagnosis of the underlying cause of pelvic pain in women is often difficult given the diversity of pathology that can generate pelvic pain.Objective: To report a rare but clinically significant cause of acute pelvic pain in women.Case Report: We describe a rare case of a periurethral abscess secondary to an infected urethral diverticulum in a 41-year-old woman. She presented to our Emergency Department with pelvic pain, dysuria, and fever of 4 days duration.Conclusion: Physical examination, imaging studies, and surgery aided in confirming the diagnosis of a periurethral abscess.

Recognition and Management of the Spectrum of Acute Laryngeal Trauma - Corrected Proof

Brett T. Comer, Thomas J. Gal — 2010-06-30

Abstract: Background: Blunt laryngeal trauma frequently takes place in the setting of more significant injuries. In the setting of multiple injuries or, more importantly, as an isolated event, missed injuries to the laryngotracheal complex can have devastating results. More importantly, underestimation of the severity of injury can result in an airway that becomes quite difficult to manage. However, early recognition and management of laryngotracheal injuries can result in minimal morbidity and the need for minimal long-term intervention.Objectives: Our goal is to heighten awareness of the severity of blunt laryngotracheal trauma and reduce both acute and long-term sequelae.Case Report: We present a series of cases representing a spectrum of seemingly benign neck injuries requiring a diversity of interventions. The cases represent worsening gradations of laryngeal trauma, and the differing presentation, work-up, and management scenarios are discussed.Conclusions: Expedient evaluation, treatment, and management of blunt laryngeal trauma results in favorable outcomes. Awareness of the potential for significant injury in the presence of benign examination based on the history of injury and confirmed by radiographic or endoscopic evaluation is paramount. Although minimal findings on examination and stable patients in the setting of blunt trauma to the neck may be as innocuous as it seems, the severity of injury may “lie beneath.”

Spontaneous Perforation of Acalculous Gall Bladder Presenting as Acute Abdomen - Corrected Proof

2010-06-28

Abstract: Background: Acute abdominal pain is commonly encountered in the emergency department (ED), but a diagnosis of gall bladder perforation (GBP) is rarely considered in the absence of predisposing factors.Objectives: This article will highlight the risk factors, diagnosis, and management of GBP, a rare but potentially life-threatening biliary pathology.Case Report: A 73-year-old diabetic man presented to the ED with a 12-h history of severe upper abdominal pain. He was hemodynamically stable, but abdominal examination showed distention, guarding, and diffuse tenderness. Abdominal X-ray study showed mildly distended small bowel loops without any air-fluid levels. Abdominal sonography revealed mild ascites and pericholecystic fluid collection but no gall bladder calculi. Laboratory reports documented a white blood cell count of 13,700/mm3 and elevated serum amylase of 484IU/L. A contrast-enhanced computed tomography (CT) scan of the abdomen suggested discontinuity of the gall bladder wall along with fluid accumulation in the pericholecystic, perihepatic, right subphrenic, and right paracolic spaces. In view of the possibility of spontaneous GBP developing as a complication of acute acalculous cholecystitis, laparotomy was planned. At surgery, several liters of bile-stained peritoneal fluid were aspirated and inspection of the gall bladder revealed a perforation at the fundus. After cholecystectomy, the patient had an uneventful recovery.Conclusion: The diagnosis of spontaneous gall bladder perforation should be considered in elderly patients presenting to the ED with symptoms and signs of peritonitis even in the absence of pre-existing gall bladder disease. Abdominal CT scan is an invaluable tool for the diagnosis, and early surgical intervention is usually life-saving.

Can Intraocular Pressure Measurements Be Used To Screen For Elevated Intracranial Pressure In Emergency Department Patients? - Corrected Proof

Tim Muchnok, Ken Deitch, Patricia Giraldo — 2010-06-28

Abstract: Background: Handheld measurement of intraocular pressure (IOP) has been previously shown to accurately predict elevated intracranial pressure (ICP) in neurosurgical patients. Handheld tonometry may have clinical utility in the prediction of elevated ICP among a cohort of emergency department (ED) patients receiving lumbar puncture (LP).Objective: To ascertain the sensitivity and specificity of IOP for the prediction of elevated ICP in ED patients undergoing LP.Methods: In this prospective observational pilot study, all ED patients over the age of 18 years and undergoing LP in the ED for any reason were eligible to participate. Study participants had IOP measured with the Tono-Pen XL (Reichert, Inc., Depew, NY) while in the supine position before LP. OP was measured in the lateral recumbent position. Elevated IOP was defined as≥20mm Hg; elevated ICP was defined as≥20mm H2O.Results: There were 82 patients screened and 46 patients enrolled at the time of interim analysis. Of the 46 patients, 32 had a successful LP in the lateral recumbent position. There were 18/32 patients with a successful LP in the lateral recumbent position who had elevated opening pressure; 9/32 patients with a successful LP had an elevated IOP. Furthermore, 4/9 patients with elevated IOP also had an elevated opening pressure. There was only one patient who had elevated IOP, elevated ICP, and diagnostic cerebrospinal fluid (sensitivity 24%, 95% confidence interval [CI] 9–48%; specificity 63%, 95% CI 32–88%; positive predictive value 28%, 95% CI 14–47%; negative predictive value 72%, 95% CI 53–96%).Conclusions: Handheld tonometry has poor sensitivity and specificity for the prediction of increased ICP, and should not be used as a screening tool in the ED.

Utilization of Emergency Medical Services by Patients with Acute Coronary Syndromes in the Arab Gulf States - Corrected Proof

2010-06-28

Abstract: Background: Emergency Medical Services (EMS) play a central role in caring for patients with acute coronary syndromes (ACS). To date, no data exist on utilization of EMS systems in the Arab Gulf States.Objective: To examine EMS use by patients with ACS in the Gulf Registry of Acute Coronary Events (Gulf RACE). Methods: Gulf RACE was a prospective, multinational study conducted in 2007 of all patients hospitalized with ACS in 65 centers in six Arab countries. Data were analyzed based on mode of presentation (EMS vs. other).Results: Of 7859 patients hospitalized with ACS through the emergency department (ED), only 1336 (17%) used EMS, with wide variation among countries (2% in Yemen to 37% in Oman). Younger age (odds ratio [OR] 1.09; 95% confidence interval [CI] 1.03–1.15 per 10-year decrement), presence of chest pain (OR 1.73; 95% CI 1.48–2.03), prior myocardial infarction (OR 1.58; 95% CI 1.34–1.86), prior percutaneous coronary intervention (OR 1.27; 95% CI 1.02–1.59), family history of premature coronary disease (OR 1.25; 95% CI 1.09–1.51), and current smoking (OR 1.30; 95% CI 1.13–1.50) were independently associated with not utilizing EMS. Patients with ST-segment elevation myocardial infarction/left bundle branch block myocardial infarction who were transported by EMS were significantly less likely to exhibit major delay in presentation, and were significantly more likely to receive favorable processes of care, including shorter door-to-electrocardiogram time, more frequent coronary reperfusion therapy, and thrombolytic therapy within 30min of arrival at the ED.Conclusion: Despite current recommendations, fewer than 1 in 5 patients with ACS use EMS in the Arab Gulf States, highlighting a significant opportunity for improvement. Factors causing this underutilization deserve further investigation.

Difficulties with Gum Elastic Bougie Intubation in an Academic Emergency Department - Corrected Proof

2010-06-28

Abstract: Background: The difficulties with gum elastic bougie (GEB) use in the emergency department (ED) have never been studied prospectively.Objectives: To determine the most common difficulties associated with endotracheal intubation using a GEB in the ED.Methods: We conducted a prospective, observational study of GEB practices in our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000 patients. Laryngoscopists performing a GEB-assisted intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), reason for GEB use, and problems encountered. Data were analyzed using standard statistical methods and 95% confidence intervals.Results: A GEB was used for 88 patients. The overall success rate was 70/88 (79.6%; 95% confidence interval [CI] 71.1–88.0%). The GEB failure rate of the first laryngoscopist was 25/88 (28.4%; 95% CI 21.0–40.3%), with the two most common reasons being: inability to insert the bougie past the hypopharynx in 13 (52%; 95% CI 32.4–71.6%) and inability to pass the endotracheal tube over the bougie in six (24%; 95% CI 7.3–40.7).Conclusions: The GEB is a helpful rescue airway device, but emergency care providers should be aware that failure rates are relatively high at a teaching institution.

Achilles Tendon Rupture Must be Excluded in the Neutral, Non-fractured Ankle X-ray Study - Corrected Proof

2010-06-28

Abstract: Background: Rupture of the Achilles tendon (TA) is a common injury. Nevertheless, there is significant potential for missing the diagnosis on initial presentation. We investigated the potential role of lateral ankle X-ray studies in aiding diagnosis.Objectives: To determine the potential role of radiographs of the ankle in assisting in the diagnosis of Achilles tendon ruptures.Methods: In a regional trauma unit, 27 patients with confirmed TA rupture at operation had the “tibio-first metatarsal angle” measured as an indication of ankle neutrality. A neutral ankle was defined as an angle of≤100°. Twenty-seven patients with intact TA were used as controls.Results: The mean angle in the TA rupture group was 88° (range 70–120°) and 125° (104–146°) in the control group (p<0.001).Conclusions: In cases of TA rupture, the ankle adopts a more dorsiflexed position than in the ankle with an intact TA. We believe that an ankle joint adopting a neutral position on a lateral X-ray study of the ankle provides a clue to help reduce the rate of missed TA ruptures at initial presentation.

Treating Critical Illness Caused by the 2009 H1N1 Influenza A Virus - Corrected Proof

Azher M. Merchant, Evie G. Marcolini, Michael E. Winters — 2010-06-28

Abstract: Background: The 2009 H1N1 influenza A pandemic has set the world spinning, unexpectedly producing significant morbidity and mortality in young, otherwise healthy patients.Discussion: As the virus spreads across the Northern Hemisphere, emergency physicians are confronted with the challenging task of caring for the many that become critically ill from this pathogen. With the exception of a few observational studies and case reports, there is little information to guide the emergency physician in resuscitating and delivering critical care to a rapidly deteriorating patient. Many moribund patients with 2009 H1N1 influenza A infection require non-conventional critical care therapies.Conclusion: In this article, we describe the case of a critically ill patient with confirmed 2009 H1N1 influenza A infection. After a brief review of the unique characteristics of this virus, we discuss the management of critically ill patients burdened by infection with 2009 H1N1 influenza A.

Pediatric Vasoocclusive Crisis and Weather Conditions - Corrected Proof

2010-06-25

Abstract: Background: Previous studies have demonstrated associations of frequency of vasoocclusive crisis with weather conditions in adults, although relationships have been inconsistent.Objectives: Our objective was to determine if there is an association between weather conditions and pediatric emergency department (ED) visits, hospital admissions, and day and severity of pain precipitation for vasoocclusive crisis (VOC).Methods: A retrospective observational study was performed at a large tertiary care pediatric center. We reviewed health records of all VOC patients under the age of 18 years with a chief complaint of pain and performed correlations between daily and average weekly and monthly weather conditions and frequency of painful crises.Results: A total of 430 visits for VOC to the ED were documented from January 2005 to December 2006. Significant correlations were noted between the daily and weekly number of painful crises and colder temperatures (ρ=−0.11, p=0.004 for daily data and r=0.25, p=0.01 weekly) and wind speed (ρ=0.13, p<0.001 and r=0.25, p=0.01). The monthly number of painful crises was moderately correlated with temperatures (r=−0.42, p=0.04). The average monthly pain score was higher in more humid months (r=0.44, p=0.03).Conclusion: We found significant correlations of VOC with weather conditions where colder temperatures and higher wind speed were associated with a higher incidence of VOC in children. Health care providers as well as parents should be aware of these findings and ensure that preventive measures are instituted in patients at risk.

Case Report: Emergency Department Diagnosis of Melorheostosis in the Upper Extremity: A Rare Disease with an Unusual Presentation - Corrected Proof

Tiffany Murano, Michele Egarian — 2010-06-25

Abstract: Background: Melorheostosis is a rare disease that affects fewer than 1:1,000,000 persons worldwide and most typically affects the lower extremities. It is a non-hereditary disease that may be debilitating due to chronic pain, contractures of the soft tissue, and even shortening of the affected limbs. Although it most commonly occurs in the lower extremities, melorheostosis has been reported in various locations throughout the body.Objective: This case report describes a patient who presented to the Emergency Department (ED) with this rare disease in an uncommonly affected bone.Case Report: The patient was a 21-year-old man who presented to the ED with pain in his left upper extremity that he attributed to playing sports 3 days before presentation. Plain films revealed periosteal hyperostosis typical of melorheostosis in several of his carpals, metacarpals, and phalanges, as well as the humerus and ulna. The patient was discharged with orthopedic follow-up and pain medication.Conclusion: Melorheostosis is a rare disease that has characteristic radiographic findings likened to the appearance of melting wax flowing down the side of a candle. In certain cases, the disease can be debilitating and may require chronic pain management and even operative intervention. If this diagnosis is made in the ED, the emergency physician should provide adequate pain management and refer the patient to an orthopedic specialist for a work-up to rule out other sclerosing bone dysplasias.

Thrombolytic Therapy for Acute Ischemic Stroke beyond Three Hours - Corrected Proof

2010-06-25

Abstract: Background: Ischemic cerebrovascular accidents remain a leading cause of morbidity and mortality. Thrombolytic therapy for acute ischemic stroke within 3h of symptom onset of highly select patients has been advocated by some groups since 1995, but trials have yielded inconsistent outcomes. One recent trial demonstrated significant improvement when the therapeutic window was extended to 4.5h.Clinical Question: Does the intravenous systemic administration of tPA within 4.5h to select patients with acute ischemic stroke improve functional outcomes?Evidence Review: All randomized controlled trials enrolling patients within 4.5h were identified, in addition to a meta-analysis of these trial data.Results: The National Institute of Neurological Disorders and Stroke (NINDS) and European Cooperative Acute Stroke Study III (ECASS III) clinical trials demonstrated significantly improved outcomes at 3 months, with increased rates of intracranial hemorrhage, whereas ECASS II and the Acute Noninterventional Therapy in Ischemic Stroke (ATLANTIS) study showed increased hemorrhagic complications without improving outcomes. Meta-analysis of trial data from all ECASS trials, NINDS, and ATLANTIS suggest that thrombolysis within 4.5h improves functional outcomes.Conclusion: Ischemic stroke tPA treatment within 4.5h seems to improve functional outcomes and increases symptomatic intracranial hemorrhage rates without significantly increasing mortality.

Short Stay Management of Chest Pain - Corrected Proof

Edward J. Otten — 2010-06-25

When I was a medical student, a common debate among us was, “Is medicine a science or an art?” The more enlightened of us thought it a combination of the two; unfortunately, we were wrong. Medicine is a business. Although there may be some scientific basis for what we do and a lot of art in the practice of medicine, the bottom line is what rules. The days of admitting patients to the hospital for a week to rule out a myocardial infarction (MI) are long gone. Hospital administrators are pushing for shorter and shorter stays, regardless of whether we make the diagnosis, educate the patient, or begin therapy. Modern technology has replaced experience and gestalt. Missed MI accounts for the single highest malpractice award; every juror knows that chest pain equals MI. The population is aging, people are more obese, glucose and cholesterol are rising, coronary arteries are closing, emergency departments (EDs) are filling up, and people are dying.

Dysrhythmiartifact - Corrected Proof

Sony Jacob, Joya A. Ganguly, Naga V.A. Kommuri — 2010-06-25

A 68-year-old woman with a medical history significant for dyslipidemia and diabetes mellitus presented to the Emergency Department with pre-syncope. On arrival, she was found to be mildly hypertensive, but otherwise stable. Her physical examination was within normal limits, and her chest X-ray study was unremarkable. A 12-lead electrocardiogram (ECG), obtained on a General Electric/Marquette MAC 5000 was suspicious for a dysrhythmia (A, ). It appeared to be atrial in nature, with the resemblance of electrical deflections similar to “pacemaker spikes” with a cycle length of 50 ms. All leads were involved, but the amplitude of these “pacemaker-like spikes” was more in the inferior and inferolateral leads, and minimal in leads 1 and V1. The stability of the amplitude of the artifacts in the limb leads suggested that the source of the artifact had to have a fixed position and inferior orientation relative to the patient's body. On further discussion, it was discovered that the patient had a history of neurogenic bladder, for which a spinal neurostimulator (InterStim®; Medtronic, Minneapolis, MN) was implanted subcutaneously on the lower back for bladder control. The device was deactivated later and the artifact disappeared (B).

Last Call - Corrected Proof

Edward J. Otten — 2010-06-25

The “last call,” as anyone associated with a fire department knows, is the radio call made for someone after their death and, obviously, goes unanswered. It is symbolic of the dedication and commitment that the deceased had to the fire service during his or her life and the respect that the deceased person's colleagues had for him or her. The Last Call reviewed here is the story of a rural fire department in central Ohio; its birth, life, death, and “final call,” which mirrors not just this particular department but, likely, the end of a long and brave tradition of similar departments. Many of us growing up in the 1960s remember what it was like when most of the rural fire departments in the United States were volunteer and, using donated equipment and on-the-job training, responded to fires and other emergencies. I was a volunteer fireman (the correct term now is “firefighter”) when I was in college and, based on my Army training as a medic, acted as an emergency medical technician (EMT) before there were such titles. At one time, only two of us knew cardiopulmonary resuscitation, and when the fire siren went off, even if you were in organic chemistry lab, you ran for the firehouse. The professors understood that we were the only fire response in the community and they were very supportive Where did these volunteers come from? How did these early departments evolve into modern emergency medical systems (EMS)? Why did minimally trained and equipped firefighters risk their lives in burning buildings? Charles Rice is a PhD in psychology and editor-in-chief of The Psychological Record, and he knows about human behavior and motivation. His experience over 30 years with a small rural volunteer fire department and his insight into the character of the people he worked with and what he learned from them makes great reading. It is not just the historical aspects of the story, but the human comedy that makes this a quite interesting and informative work. The subtitle of this book is “Sweat, Tears, and Beers: Thirty Years at the Firehouse.” Dr. Rice's training as a keen observer of human nature, and his witty and engaging style bring to life the daily activities of the College Township Volunteer Fire Department (CTFD).

Retropharyngeal Abscess with Descending Necrotizing Mediastinitis - Corrected Proof

Kai-Yuan Wang, Hung-Jung Lin, Yi-Hsien Chen — 2010-06-21

A 64-year-old man with a history of liver cirrhosis presented to the Emergency Department with neck pain and a sore throat that had lasted 3 days. He experienced progressive dysphagia and choked frequently. He sought medical help in a local clinic and was treated for pharyngitis. On examination, tachypnea with use of the accessory respiratory muscles along with swelling of the tonsils and posterior pharynx were noted. The lateral neck radiograph showed a widened prevertebral space (). The patient collapsed suddenly, and was intubated immediately. The supine chest roentgenograph showed widening of the mediastinum. A computed tomography (CT) scan of the chest and neck was performed, and revealed a retropharyngeal abscess with spread to the deep neck, submandibular spaces, and upper mediastinum (). Despite emergent treatment with radical debridement and intravenous antibiotics, the patient expired 2 days later.

Malaria in Pregnancy: Update on Emergency Management - Corrected Proof

Janet Smereck — 2010-06-21

Abstract: Background: Pregnancy complicates the diagnosis, treatment, and clinical course of malaria. This clinical problem may be encountered in emergency department patients due to international travel.Case Report: A primigravida woman at 20 weeks gestation presented to the Emergency Department with episodic fever, chills, headache, and nausea after travel to India and Asia. She had not taken malaria prophylaxis. After hospitalization, she developed acute respiratory distress syndrome and required intensive care management. Although she ultimately recovered from severe infection with Plasmodium vivax, she was not able to sustain her pregnancy and suffered a miscarriage.Conclusion: This case illustrates the serious nature of malaria in the pregnant patient. For this high-risk group, there is an increased incidence of severe anemia, as well as acute respiratory distress syndrome and pulmonary edema. A guideline is presented for the initial choice of anti-malarial drug treatment for the pregnant patient.

Lizard Bites of the Head and Neck - Corrected Proof

Ryan N. Heffelfinger, Patricia Loftus, Christina Cabrera, Edmund A. Pribitkin — 2010-06-21

Abstract: Background: As the ownership of lizards becomes more prevalent in the United States, injuries from these exotic pets will increase. Emergency and primary care physicians must be familiar with the proper management of lizard bites to the head and neck.Objectives: The aim of this case report is to discuss the potential complications and proper management of lizard bites to the head and neck.Case Report: A 47-year-old man presented to the emergency department 3h after his 5-foot iguana bit his face. The wounds were irrigated and primarily closed. Tetanus prophylaxis was administered. He was given oral amoxicillin/clavulanate potassium for 7 days. Sutures were removed 1 week after the repair.Conclusions: Topical antiseptic care, verification of tetanus status, primary wound closure, and careful monitoring of non-venomous lizard bites is recommended for lizard bites to the head and neck. Wounds at risk for infection should be treated with a quinolone or other antibiotics covering Salmonella as well as human skin flora. Venomous lizard (e.g., Gila monster and Mexican Beaded Lizard) bites require prompt attention due to potentially significant morbidities including anaphylaxis, disseminated intravascular coagulation, and acute myocardial infarction.

Fusobacterium Septicemia Complicated by Cerebral Subdural and Epidural Empyemas: A Rare Case of Lemierre Syndrome - Corrected Proof

Hao-Wen Teng, Chia-Yuen Chen, Huan-Chieh Chen, Wen-Ting Chung, Wen-Sen Lee — 2010-06-21

Abstract: Background: Lemierre syndrome is characterized by postanginal septicemia and internal jugular vein thrombophlebitis with secondary septic emboli, typically to the lungs. The central nervous system (CNS) is rarely involved.Objective: To present a case of Lemierre syndrome featuring cerebral subdural and epidural empyemas.Case Report: This case report describes the case of a 17-year-old youth with cerebral subdural and epidural empyemas. The findings of chest computed tomography of the neck and the blood cultures were compatible with Lemierre syndrome. The patient recovered well after antibiotic treatment and surgical debridement.Conclusion: Lemierre syndrome can result in infection spreading to the CNS, including cerebral subdural and epidural empyemas. This disease entity should be included in the differential diagnoses of CNS bacterial infections.

Self-inflicted Orbital and Intracranial Pencil - Corrected Proof

Jonathan Rosenson, Daniel Mantuani — 2010-06-21

A 60-year-old man presented to the Emergency Department with a self-inflicted wooden pencil in the right orbit. Medical history included bipolar disorder with multiple prior incidents of self-harm. The patient reported antipsychotic medication non-compliance for several weeks before presentation. Physical examination was notable for a wooden pencil in the right lateral orbit () with decreased extraocular movements and proximal conjunctival injection. Visual acuity, pupillary responses, and fundoscopic examination were normal. The motor, sensory, and cerebellar components of the neurological examination were all intact; the cranial nerve examination was intact except for limited extraocular movements in the affected eye.

Hyperglycemia-induced Hemiballismus Hemichorea: A Case Report and Brief Review of the Literature - Corrected Proof

Shivakumar Narayanan — 2010-06-21

Abstract: Background: Metabolic conditions, including hyperglycemia, can have various neurological presentations. Hemiballismus hemichorea is a rare manifestation reported to occur with severe hyperglycemia and is reversed in most cases with control of sugars.Case Report: We present a case of a patient with no known diabetes history who presented with uncontrolled jerky movements of one-half of her body, which resolved with achievement of euglycemia.Conclusions: Important differential diagnoses that need to be evaluated are discussed.

Amlodipine Toxicity vs. Exposure in Children - Corrected Proof

Daniel M. Lugassy, Jennifer A. Martin, Robert S. Hoffman — 2010-06-21

To the Editor: We read with interest the recent article regarding amlodipine toxicity in children . Although we agree that amlodipine poisoning poses significant risks in children, we are weary of some of the assumptions made by the authors. The limitations of the poison center data system have been well recognized for many years and published elsewhere . Without reiterating all of its inequities, we must remember that data collected reflect “exposures,” which are unreliable when no attempt is made to confirm “ingestions” by either qualitative or quantitative testing. This confusion is carried throughout the article, beginning with the title that should read “Amlodipine Exposure” not “Amlodipine Toxicity.” Similarly, when the discussion states that the study comprises the largest cohort of pediatric amlodipine ingestions reported to date, the authors clearly overstep their bounds because, with the exception of the symptomatic children, it is quite possible that no other child has even ingested any amlodipine. Exposures do not equal ingestions.