American Journal of Emergency Medicine - Articles in Press

A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax - Corrected Proof

Khoy Kheng Ho, Marcus Eng Hock Ong, Mariko Siyue Koh, Evelyn Wong, J. Raghuram — 2010-08-18

Abstract: Objectives: The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED).Methods: Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days.The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up.Results: There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, −0.20; 95% confidence interval, −0.38 to −0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates.Conclusion: Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

Acute onset quadriparesis with sine wave: a rare presentation - Corrected Proof

Arif Wahab, R.B. Panwar, Vipin Ola, Shaista Alvi — 2010-08-18

Secondary hyperkalemic paralysis is a rare disease entity, and initial presentation with sine wave pattern is even rarer. We report a case of acute onset flaccid quadriparesis due to hyperkalemia and sine wave pattern in electrocardiogram.

A novel hands-free carotid ultrasound detects low-flow cardiac output in a swine model of pulseless electrical activity arrest - Corrected Proof

2010-08-16

Abstract: Objective: To determine if a hands-free, noninvasive Doppler ultrasound device can reliably detect low-flow cardiac output by measuring carotid artery blood flow velocities. We compared the ability of observers to detect carotid artery flow velocity differences between pseudo-pulseless electrical activity (PEA) and true-PEA cardiac arrest.Methods: Five swine were instrumented with aortic (Ao) and right atrial pressure-transducing catheters. The Doppler ultrasound device was adhered to the neck over the carotid artery. Continuous electrocardiogram, pressure readings, and Doppler signal were recorded. Each swine underwent multiple episodes of fibrillation and resuscitation. Episodes of true-PEA and pseudo-PEA were retrospectively identified from all resuscitation attempts by examination of electrocardiogram and Ao waveforms. The sensitivity and specificity of the device to detect pseudo-PEA was obtained using observers blinded to Ao waveform recordings.Results: There was good interobserver reliability related to identification of pseudo- and true-PEA (κ = 0.873). The observers blinded to Ao waveform recordings agreed on 8 of the 9 episodes of pseudo-PEA, whereas 4 false positives of 26 true-PEA events were reported (sensitivity, 0.89; specificity, 0.85). The Doppler device was able to detect carotid flow velocity over a wide range of Ao blood pressures.Conclusions: This hands-free, noninvasive Doppler ultrasound device can reliably differentiate pseudo-PEA from true-PEA during resuscitation from cardiac arrest, detecting pressure gradient changes of less than 5 mm Hg through to normotension. This device distinguishes conditions of no cardiac output from low cardiac output and may have applications for use during resuscitation from various etiologies of arrest and shock.

Epidemiology of strain/sprain injuries among cheerleaders in the United States - Corrected Proof

Brenda J. Shields, Gary A. Smith — 2010-08-16

Abstract: Objective: The aim of this study is to describe the epidemiology of cheerleading-related strain/sprain injuries by type of cheerleading team and type of event.Methods: Athlete exposure (AE) and injury data were collected from 412 United States cheerleading teams via the Cheerleading Reporting Information Online surveillance tool, and injury rates were calculated.Results: Strains/Sprains were the most common injury (53%; 0.5 injuries per 1000 AEs) sustained by cheerleaders during our 1-year study. The lower extremities (42%), particularly the ankles (28%), were injured most often. Most injuries occurred during practice (82%); however, the rate of injury was higher during competition (0.8 injuries per 1000 AEs; 95% confidence interval [CI], 0.6-1.0) than during practice (0.6 injuries per 1000 AEs; 95% CI, 0.5-0.6) for all team types. Injuries were sustained most frequently by high school cheerleaders (51%), although college cheerleaders had the highest injury rate (1.2 injuries per 1000 AEs). Strains/Sprains occurred most frequently while attempting a stunt (34%) or while tumbling (32%). Spotting/Basing other cheerleaders (19%) was the most common mechanism of injury and was more likely to result in a lower back strain/sprain than other mechanisms of injury (odds ratio, 3.38; 95% CI, 1.41-8.09; P < .01).Conclusions: Cheerleaders should increase their focus on conditioning and strength-building training, which may help to prevent strain/sprain injuries. Spotters and bases should additionally focus on proper lifting technique to help avoid back injury. Guidelines may need to be developed for return-to-play after cheerleading-related strain/sprain injuries.

Pediatric abscess characteristics associated with hospital admission from the ED - Corrected Proof

2010-08-16

Abstract: Objective: To determine the characteristics of pediatric soft tissue abscesses that result in hospital admission.Methods: All visits for soft tissue abscesses to the study emergency department (ED) were examined during 2008.Detailed records were reviewed to determine ED disposition, abscess size, location, presence of fever, duration of symptoms, previous antibiotic therapy, prior ED visit(s), and wound and blood culture results. Data were analyzed to determine which of these characteristics were associated with hospital admission from the ED.Results: Six hundred twenty-two patients met the inclusion criteria. One hundred thirteen (18%) patients were admitted to the hospital and 509 (82%) were discharged home. Compared to those sent home, abscesses resulting in admission were more likely to be located in the genital area (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.37-6.90), breast (OR, 4.8; 95% CI, 1.08-21.4), or face (OR, 4.39; 95% CI, 1.86-10.3), and were more likely to be larger than 3 cm (OR, 3.66, 95% CI, 2.10-6.36). Patients who were admitted to the hospital were also more likely to have fever (OR, 5.93; 95% CI, 3.4-10.3) and have had a prior ED visit with the same complaint (OR, 3.81; 95% CI, 1.77-8.2). Seventy-seven percent of abscesses that were cultured were positive for methicillin-resistant Staphylococcus aureus.Conclusions: Size and location (especially those in the genital region, breast, and face), appear to be associated with admission for pediatric abscesses. History of fever and previous ED visit also appear to be associated with hospital admission. Obtaining blood cultures for pediatric abscesses is likely of little clinical benefit.

Hypothermia is associated with poor outcome in pediatric trauma patients - Corrected Proof

2010-08-16

Abstract: Objective: The objective of the study was to determine if hypothermia in pediatric trauma patients is associated with increased mortality.Methods: We reviewed the charts of level 1 trauma patients aged 3 months to 17 years who presented between September 2006 and March 2008. We analyzed data for patients with temperatures recorded within 30 minutes of arrival to the pediatric emergency department. Logistic regression models were used to test for associations of hypothermia with death while adjusting for mode of transport, season of year, and presence of intracranial pathology as documented by an abnormal head computed tomographic scan.Results: Of the 226 level 1 trauma patients presenting during the study period, 190 met inclusion criteria. Twenty-one patients (11%) died. The odds ratio (OR) of a hypothermic patient dying was 9.2 times that of a normothermic patient when adjusting for seasonal variation (95% confidence interval [CI], 3.2-26.2; P < 0.0001). The OR of a hypothermic patient dying was 8.7 times that of a normothermic patient when adjusting for mode of transport (ground vs air) (95% CI, 3.1-24.6; P < 0.0001). Although it did not reach statistical significance, there was a trend toward an association between hypothermia and the presence of traumatic brain injury as evidenced by an abnormal head computed tomographic scan (OR = 2.4; 95% CI, 0.9-6.0; P = .07).Conclusions: Hypothermia is a risk factor for increased mortality in pediatric trauma patients. This pilot study warrants a more detailed, multicenter analysis to assess the impact of hypothermia in the pediatric trauma patient.

The Pulmonary Embolism Rule-Out Criteria rule in a community hospital ED: a retrospective study of its potential utility - Corrected Proof

Robert J. Dachs, Divya Kulkarni, George L. Higgins — 2010-08-16

Abstract: Background: The Pulmonary Embolism Rule-Out Criteria (PERC) rule identifies patients who can be safely discharged from the emergency department (ED) without undergoing laboratory or radiological investigation for possible pulmonary embolism (PE). It was shown to be 99% sensitive in a large validation series. Our objective was to assess the PERC rule's performance in a representative US community hospital.Methods: A chart review of ED patients receiving computed tomographic scans (CTS) for possible PE during a 4-month study period was performed. The PERC rule was applied to this cohort, and its sensitivity and negative predictive value were determined.Results: Two hundred thirteen patients underwent chest CTS to “rule out” PE. Forty-eight patients met PERC rule criteria, and all had negative CTS. Of the remaining 165 patients, 18 patients (11%) had scans positive for PE. The overall prevalence of PE was 8.45% (95% CI, 5.22-13.24%). The PERC rule's sensitivity was 100% (95% CI, 78.12-100%), with a negative predictive value of 100% (95% CI, 90.80-100%). Application of the PERC rule at the point-of-care would have reduced CTS by 23%.Conclusions: In our community hospital, the PERC rule successfully identified ED patients who did not require CTS evaluation for PE. Had the PERC rule been applied, nearly one-quarter of all CTS performed to “rule out PE” could have been avoided.

Emergency endoscopic decompression of a delayed posttraumatic tension gastrothorax - Corrected Proof

Ausami Abbas, Manish Thakker, Michael Booth, Ian Rechner — 2010-08-16

Tension gastrothorax is a rare, potentially life-threatening complication associated with diaphragmatic defects. Most reported cases in the literature have described this condition as a complication of congenital diaphragmatic hernia, in patients with hiatus hernia, or in the postoperative setting. It is an extremely rare complication following diaphragmatic injury and usually manifests as a delayed presentation of an undiagnosed traumatic diaphragmatic hernia. Early diagnosis and differentiation from other conditions that are more commonly associated with “tension” phenomena are essential. We describe the case of a 30-year-old man who presented to the emergency department with respiratory distress and left upper quadrant abdominal pain and clinically had mediastinal shift. The diagnosis of tension gastrothorax was made based on clinical and radiological findings. We discuss the various methods proposed in the literature for the emergency decompression of a tension gastrothorax and highlight the use of an emergency endoscopic approach as a potential alternative in cases where decompression by nasogastric tube insertion is unsuccessful.

Sonographic bedside detection of sialolithiasis with submandibular gland obstruction - Corrected Proof

Beatrice Hoffmann — 2010-08-16

Sialolithiasis with salivary gland obstruction is a rare disease and can mimic more frequently occurring illnesses such as facial and dental infection or abscess. Salivary stones located in the gland or duct system can be diagnosed using high-frequency sonography, and these findings can be differentiated from ultrasound appearance of cellulitis and abscess. Additional information obtained by sonography such as number, size, and location of stones help determine prognosis of stone passage and can guide initial management of the symptomatic patient in the emergency setting. We present the case of a young female coming to the emergency department (ED) with worsening left-sided jaw pain and swelling in which emergency physician–performed sonography assisted with the diagnosis of sialolithiasis and obstructive submandibular gland disease. This diagnostic approach helped successfully guide ED management of the patient without the need for computed tomography.

Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work - Corrected Proof

Bradley D. Shy, Ian Portelli, Lewis S. Nelson — 2010-08-16

Abstract: Objectives: We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions.Methods: We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives.Results: Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%).Conclusion: Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.

Metformin-associated lactic acidosis treated with prolonged hemodialysis - Corrected Proof

2010-08-16

Metformin-associated lactic acidosis is a well-recognized complication in diabetic patients receiving metformin. Only a few cases of voluntary metformin intoxication presented with metformin-associated lactic acidosis have been reported, and they mostly described patients with diabetes mellitus. Cases of voluntary acute metformin intoxication in nondiabetic, previously healthy subjects are rarely reported, and their characteristics and prognosis are less known. We report a 34-year-old healthy man who presented to the emergency department after taking 170 metformin 850-mg tablets in a suicide attempt. The patient developed severe lactic acidosis and acute renal failure, which were completely resolved after prolonged hemodialysis.

Pharmacologic unilateral mydriasis due to nebulized ipratropium bromide - Corrected Proof

2010-08-16

A 76-year-old female patient, while receiving nebulized ipratropium bromide and salbutamol treatment of pneumonia and dyspnea, developed mydriasis in the left eye (left, 6 mm; right, 2 mm) on the third day of the treatment. Because the patient was incoordinated to the mask treatment, leakage of the medications to the left eye occurred. The patient was diagnosed as having pharmaceutical pupil. Afterward, nebulization treatment was stopped. Within 24 hours, the pharmaceutical pupil got back to normal. Ipratropium bromide is a drug often used with salbutamol to treat patients with dyspnea. Like atropine, it is an anticholinergic. Mydriasis caused by nebulized ipratropium bromide has rarely been reported in children and adults in literature. Pharmaceutical pupil is usually unilateral and mostly on the left eye. After treatment is stopped, patients recover within 24 hours. Pilocarpin test can be applied to differentiate the diagnosis from other neurologic and ophthalmologic reasons like third nerve palsy and Adie pupil. Pilocarpin affects the eye as parasympathomimetic agents do. Diagnosis can be made without carrying out time-consuming and expensive tests through the awareness of the clinician and the pilocarpin test.

Oxcarbazepine-induced resistant ventricular fibrillation in an apparently healthy young man - Corrected Proof

Ayman El-Menyar, Mazhar Khan, Jassim Al Suwaidi, Esam Eljerjawy, Nidal Asaad — 2010-08-16

We report a 30-year-old man with recurrent loss of consciousness. His resting electrocardiogram revealed Brugada pattern. The patient developed resistant ventricular fibrillation after receiving oral oxcarbazepine. The clinical, echocardiographic, and electrocardiographic features are discussed in brief.

Utility of routine thyroid-stimulating hormone determination in new-onset atrial fibrillation in the ED - Corrected Proof

2010-08-16

Abstract: Introduction: Hyperthyroidism is a relative uncommon but important cause of atrial fibrillation. The aim of this study was to investigate the utility of routine thyroid-stimulating hormone (TSH) determination in the emergency department (ED) in patients presenting to the ED with stable, new-onset atrial fibrillation. We derive a set of clinical criteria in which TSH is likely to be normal and therefore thyroid function evaluation deferrable to a different time from ED visit.Methods: Cross-sectional observational study in a university hospital. Thyroid-stimulating hormone was measured in all patients admitted to the ED observational unit for new-onset atrial fibrillation in a 30 consecutive months' period. Patients' clinical characteristics and treatment received in the ED were recorded. Recursive partitioning analysis technique was used to determine which predictors were associated with a TSH level less than 0.35 μIU/mL.Results: Of 433 patients enrolled, 47 (10.8%) had a low TSH. Thyroid-stimulating hormone highly correlated with FT3 and FT4 levels (P < .001) confirming its good predictive value as screening tool.Recursive partitioning analysis showed that previous thyroid disease (P < .01), stroke/transient ischemic attack (P < .01), and hypertension (P = .10) were associated with low TSH. The final model had sensitivity of 93% and specificity of 31%, corresponding to a negative likelihood ratio of 0.02 (0.01-0.07).Conclusion: Hyperthyroidism is present in nearly 10% of new-onset atrial fibrillation. Although thyroid function screening is recommended in all patients, a simple model that included previous thyroid disease, stroke, and hypertension might help to identify those patients at high risk (low TSH) in the ED.

Large left upper quadrant mass - Corrected Proof

Amy A. Ernst, Steve J. Weiss, David A. Wachter, Michael D. Stifelman — 2010-08-16

Causes of left upper quadrant (LUQ) masses include spleen, colonic, pancreatic, and renal etiologies. Emergency department (ED) ultrasound can help differentiate the cause. In this article, we present the case of a 53-year-old female attending Emergency Medicine physician diagnosed with a large palpable LUQ mass. The mass was noted after an episode of moderate nausea and mild LUQ, left lower quadrant, and flank pain. The pain and nausea resolved the following day. The mass was palpable about 10 cm below the left costal margin and was thought initially to be the spleen. In the ED, a bedside ultrasound revealed a normal spleen with a grossly abnormal kidney with severe hydronephrosis. Plain computed tomography scan showed congenital ureteropelvic junction obstruction. Magnetic resonance imaging revealed crossing inferior renal vessels as the cause. The subject underwent a robotic dismembered pyleoplasty. Left upper quadrant mass differential should include ureteropelvic junction obstruction; bedside ED ultrasound is useful in the diagnosis.

Hyperbaric oxygen therapy in a case of cholesterol crystal embolization - Corrected Proof

2010-08-16

Cholesterol crystal embolism (CCE) is a multiorgan disease, with a high morbidity and mortality rate. This syndrome may occur spontaneously, but more often is a severe iatrogenic complication of an invasive vascular procedure. It is an increasing and still underdiagnosed disease; in fact, its real incidence is unknown. Skin and kidneys are most frequently involved, but any organ can be affected. Biopsy of the ischemic lesions is essential for diagnosis. There is still no established standard treatment of CCE. We report the case of a 56-year-old man who developed CCE with involvement of skin and kidneys 2 weeks after coronary angioplasty. After a long, unsuccessful treatment with high-dose statins, prednisone, and iloprost, hyperbaric oxygen therapy was effective to improve ischemia of distal extremities and renal function and to relieve pain. This is the first case in which the efficacy of hyperbaric oxygen in CCE was tested.

A case of rivastigmine toxicity caused by transdermal patch - Corrected Proof

Duk Hee Lee, Yoon Hee Choi, Kwang Hyun Cho, Soon Young Yun, Hyung Min Lee — 2010-08-16

Rivastigmine is a carbamate cholinesterase inhibitor used in the treatment of dementia. Toxicity is expected to resemble poisoning from other carbamates and organophosphates with features of both muscarinic (salivation, lacrimation, urination, defecation, miosis, bronchorrhea, and bradycardia) and nicotinic (muscle weakness, fasciculations, and paralysis) stimulation. We present a case of rivastigmine toxicity caused by transdermal patch. After removal of patches, the patient's symptoms and signs were spontaneous recovery without atropine and oxime therapy. Emergency physicians should be aware of the signs of increased nicotinic, muscarinic, and central nervous system effects (seizure), which are the same as with organophosphate and carbamate toxicities, and strongly consider carbamate cholinesterase inhibitor (rivastigmine) overdose.

Spontaneous urinoma: an unexpected cause of acute abdomen - Corrected Proof

2010-08-16

We report the case of a 52-year-old man who presented with severe acute abdominal pain. Physical examination and laboratory findings were not indicative of a specific diagnosis, and an abdominal computed tomography scan revealed dilatation of the left pelvicalyceal system and fluid collection in the ipsilateral perirenal space. A thorough overlook of postcontrast and delayed postcontrast images revealed a small calculus situated at the ureterovesical junction and identified the collection as a urinoma. The patient was treated with prophylactic antibiotics and analgesics, and symptomatology improved rapidly, whereas the perirenal fluid was absorbed completely as shown in a repeat computed tomography scan 24 hours later. Our case shows that rare entities, such as urinoma, can present as etiological factors of acute abdomen and underlines the critical role of the radiologist in unveiling the diagnosis. It is thus of paramount importance for physicians in the emergency department to consider rare and “unfamiliar” diseases in the differential diagnosis of acute abdominal pain to offer proper diagnosis and avoid unnecessary and even hazardous management.

Ultrasound-guided intercostal nerve block for traumatic pneumothorax requiring tube thoracostomy - Corrected Proof

2010-08-16

A 39-year-old woman presented to our emergency department 3 days after an assault. Initial evaluation demonstrated a right pneumothorax. Given her hemodynamic stability, a series of ultrasound-guided intercostal nerve blocks were performed. The indications, technique, and advantages of this approach are reviewed.

Thrombolysis for massive pulmonary embolism in pregnancy: a case report - Corrected Proof

2010-08-16

Mortality from pulmonary embolism (PE) in pregnancy might be related to challenges in targeting the right population for prevention, ensuring that diagnosis is suspected and adequately investigated, and initiating timely and best possible treatment of this disease. We present here the case of a pregnant woman patient with massive PE successfully thrombolysed. A 42-year-old pregnant (at 14 weeks) woman was admitted 2 hours after onset of sudden acute dyspnea and chest pain. Immediate electrocardiogram showed typical S1-Q3-T3 pattern and incomplete right bundle branch block. The echocardiogram showed a distended right ventricle with free-wall hypokinesia and displacement of the interventricular septum toward the left ventricle. Thrombolysis with recombinant tissue plasminogen activator and heparin (alteplase 10 mg bolus, then 90 mg over 2 hours) was administered. Pelvic examination and ultrasound showed regular fetal heart beat, regular placental, and liquid presence. No problem in the subsequent days was evidenced for mother and fetus and at discharge. In conclusion, in pregnant patient with life-threatening massive PE, thrombolytic therapy could be administered, and the use of echocardiographic, laboratory, and clinical data could be useful tools to achieve a rapid diagnosis and a therapeutic decision, but additional studies need to be performed to further define its use.

Impact of portable ultrasound in trauma care after the Haitian earthquake of 2010 - Corrected Proof

2010-08-16

Portable ultrasound in mass casualty disasters has emerged as a useful imaging modality to aid in clinical care and victim triage . As portable ultrasound technology has become more durable, and charitable programs can rapidly provide machines to deploy with humanitarian workers, it has become possible to routinely use this imaging modality in disaster triage settings. Although a wide variety of potential ultrasound applications in mass casualty patient care exists , prior published studies of use of ultrasound in disaster are limited to abdominal hemoperitoneum and renal Doppler studies in patients with crush injury . We present here our experience in use of hand-carried ultrasound during care of earthquake victims after the Haitian earthquake of January 2010.

Circadian, weekly, and seasonal mortality variations in out-of-hospital cardiac arrest in Japan: analysis from AMI-Kyoto Multicenter Risk Study database - Corrected Proof

2010-08-16

Abstract: Background: Several studies have reported circadian, weekly, and seasonal variations in the rates of out-of-hospital cardiac arrest (OHCA). However, variations in the mortality of OHCA are not well known.Methods and Results: We investigated the 1396 consecutive cases of OHCA with cardiac etiology between October 2004 and September 2008. There were 2 peaks in the occurrence of OHCA in early morning and late evening. There was a weekly pattern with an increased incidence on Mondays. We found a significant seasonal variation in the frequency of events, with a maximum during winter. There was a trend of reduced mortality in warmest 3 months, especially among a subgroup of ventricular fibrillation/pulseless ventricular tachycardia with arrest witnessed.Conclusion: The present analyses demonstrated circadian, weekly and seasonal variations in the occurrence, and a seasonal variation in mortality in OHCA. Changes in temperature might influence the severity of OHCA and change the rate of success of cardiopulmonary resuscitation.

The Airtraq laryngoscope for emergency tracheal intubation without interruption of chest compression - Corrected Proof

Ruggero M. Corso, Emanuele Piraccini, Vanni Agnoletti, Giorgio Gambale — 2010-08-16

The 2005 American Heart Association Cardiopulmonary Resuscitation (CPR) Guidelines emphasize minimizing the interruption of chest compression to maximize coronary and cerebral perfusion pressure . More specifically, these guidelines suggest that skilled operators should be able to secure the airway either without interrupting chest compression or with only a brief pause to visualize vocal cords to allow the passage of the tracheal tube (TT). Previous studies have shown that chest compression prolongs the time needed for intubation and increases the risk of esophageal intubation . Standard direct laryngoscopic tracheal intubation remains the preferred technique to secure the airways. However, sufficient experience is required to be proficient in using this technique. In an emergency situation, airway management is often performed by a less experienced physician, in suboptimal conditions. This may affect a patient's morbidity . Introduction of video laryngoscopes might have benefits in these situations. The Airtraq is a disposable video laryngoscope with an anatomically shaped blade that has 2 parallel conduits: the optical and guiding channels (). A low temperature battery-operated light is present at the tip of the blade. The optical channel contains a high definition optics system, which transmits the image to the proximal viewfinder using a combination of lenses and prisms. An antifog system is built into the optical channel, which requires 30 to 45 seconds of warm-up time. To use the Airtraq, the TT is preloaded in a track next to the optical pathway, and the device is inserted in the oropharynx. When the glottis is visualized, the TT is advanced down the track into the trachea and the Airtraq is removed. This device has been favorably evaluated in a number of studies . It has been used in cases of failed conventional intubation and in patients with cervical spine immobilization . We report a case of a 61-year-old man presented to our Medical Emergency Team for in-hospital cardiac arrest in radiology suite. His initial cardiac arrest rhythm was ventricular fibrillation. Restoration of a spontaneous circulation occurred after 20 minutes of advanced cardiac life support (including endotracheal intubation with the Airtraq, regular size). The tube passed through the vocal cords, and there was no interruption to chest compression. After admission to intensive care unit, the patient was successfully discharged after 3 days without further adverse events.

Novel use of a urine pregnancy test using whole blood - Corrected Proof

Joseph P. Habboushe, Graham Walker — 2010-08-16

We present the case of a 35-year-old woman with hypotension and abdominal tenderness after acute vomiting and syncope. The patient had been breast-feeding since the birth of a child 8 months earlier, was not yet menstruating, and felt that she was having a reaction to sushi. She was unable to provide a urine sample during initial evaluation, and a drop of whole blood was therefore applied to a qualitative urine human chorionic gonadotropin point-of-care test. This test result was positive for pregnancy, ultrasound revealed free fluid in the abdominal cavity, and emergency laparotomy by our gynecologists confirmed ruptured ectopic pregnancy. Often, patients are too unstable or dehydrated to provide a urine sample; and serum human chorionic gonadotropin testing may be difficult to obtain in a timely fashion. This use of the point-of-care urine qualitative test has not been previously described and may be valuable in cases where rapid diagnosis is critical.

Pneumomediastinum caused by isolated oral-facial trauma - Corrected Proof

Gerard DeMers, Jacob L. Camp, Donald Bennett — 2010-08-16

Pneumomediastinum from isolated blunt or penetrating oral-facial trauma is a rare occurrence, which can be associated with facial fractures or may be iatrogenic. We present two cases caused by high-pressure-induced facial injuries that had very different management and outcomes. The first patient had asymptomatic pneumomediastinum and an uncomplicated recovery, whereas the second had a complicated clinical course requiring extensive surgical debridement. Neither patient developed mediastinitis as a complication of pneumomediastinum. This case series illustrates isolated facial trauma causing pneumomediastinum and reviews the literature over last 20 years for similar cases. The authors advocate emergency department management of pneumomediastinum from facial trauma.

Reduced access to the National Clinicians' Post-Exposure Prophylaxis Hotline. A health care crisis - Corrected Proof

2010-08-16

To the Editor, Our team of scientists has written extensively on the recommendations of postexposure prophylaxis for emergency medical as well as operating room personnel and patients exposed to blood-borne diseases . Emergency medical and operating room personnel who sustain an occupational injury that may expose them to a blood-borne disease may be either unfamiliar with the postexposure prophylaxis that they are receiving or dissatisfied with the clinical expertise of the physicians providing postexposure prophylaxis. In these cases, there were superb 24-hour resources staffed by trained personnel in postexposure prophylaxis.

Secretory phospholipase A2: a marker of infection in febrile children presenting to a pediatric ED - Corrected Proof

2010-08-16

Abstract: Background: Fever is a common presenting complaint to the emergency department (ED), and the evaluation of the febrile child remains a challenging task.Objective: The aim of this study was to examine the relationship between secretory phospholipase A2 (sPLA2) and infection in febrile children.Methods: A prospective convenience sample of children presenting with fever to an urban pediatric ED were studied. Blood and urine cultures, a complete blood count, and serum concentrations of sPLA2 were obtained, and patients were compared based on their final diagnosis of either a viral or bacterial infection.Results: In the 76 patients enrolled, 60 were diagnosed with a viral infection, 14 with a bacterial infection, 1 with Kawasaki disease, and 1 with acute lymphoblastic leukemia. The difference in the serum concentration of sPLA2 in patients with viral infections (22 ± 34 ng/mL) versus those with bacterial infections (190 ± 179 ng/mL) was statistically significant (P < .0001). Receiver operator characteristic curve analysis revealed that sPLA2 was more accurate at predicting bacterial infection (area under the curve = 0.89) than the total white blood cell count (area under the curve = 0.71) and that a value of more than 20 ng/mL had a sensitivity of 93%, specificity of 67%, positive predictive value of 39%, and negative predictive value of 97%.Conclusion: Secretory phospholipase A2 differs significantly in children with viral versus bacterial infection and seems to be a reliable screening test for bacterial infection in febrile children.

Adult asthma exacerbations and environmental triggers: a retrospective review of ED visits using an electronic medical record - Corrected Proof

Larissa May, Marianne Carim, Kabir Yadav — 2010-08-16

Abstract: Background: Despite familiarity with triggers for asthma, there is little recent study on the association of triggers with the emergency department (ED) presentation of adult asthma exacerbation.Methods: Retrospective electronic chart review of adult patients treated in an urban teaching hospital ED with chief complaint and diagnostic coding related to asthma and upper respiratory tract infection (URI) was conducted. Monthly aeroallergen data and environmental conditions were obtained from a local allergen extract laboratory and local government sources. Data analysis was performed using Newey-West time series regression modeling with adjustment for autocorrelation or ordinary least squares linear regression modeling using outcome variables of asthma visits and admissions.Results: There were 56 747 visits, with 554 asthma visits and 1 514 URI visits. Asthma visits (R2 = 0.631) were positively correlated with tree pollen counts (correlation coefficient = 0.458 [0.152-0.765]) and average humidity (correlation coefficient = 1.528 [0.296-2.760]). Asthma admissions (R2 = 0.480) were negatively correlated with average temperature (correlation coefficient = −0.557 [−1.052 to −0.061]) when adjusting for confounding by fine particulate matter.Conclusions: The ED acute asthma exacerbation presentation is positively correlated with tree pollen and humidity, whereas need for admission is associated with dropping temperatures. These results reinforce the need for vigilance during periods of increased risk and perhaps focused preventative strategies.

The AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) trial investigators respond to inhomogeneity and temporal effects assertions - Corrected Proof

2010-08-16

We read with interest the article by Paradis et al offering a reanalysis of the AutoPulse Assisted Prehospital International Resuscitation (ASPIRE) trial originally published in 2006 . Paradis and colleagues conclude a temporal relationship existed between the AutoPulse and 4-hour survival among a post hoc study population. They report that the outcome of the intervention arm improved during the course of the study among 4 of the 5 sites, which may represent a learning curve in the intervention arm. They separate site C from these analyses because of heterogeneity and conclude that the null or negative association of the AutoPulse intervention was due to a protocol change at site C that limited the AutoPulse use, suggesting that if the AutoPulse had been deployed earlier (and for longer), the result may have been more favorable.

In flight auscultation: comparison of electronic and conventional stethoscopes - Corrected Proof

2010-08-05

Abstract: Objectives: The ability to auscultate during air medical transport is compromised by high ambient noise levels. The aim of this study was to assess the capabilities of a traditional and an amplified stethoscope (which is expected to reduce background and ambient noise) to assess heart and breath sounds during medical transport in a Falcon 50 plane.Methods: A prospective, double-blind, randomized study was performed. We tested 1 model of traditional stethoscope (Littman cardiology III) and 1 model of amplified stethoscope (Littman 3100). We studied heart and lung auscultation during real medical evacuations aboard Falcon 50 (medically configured). For each, the quality of auscultation was described using a numeric rating scale (ranging from 0 to 10, with 0 corresponding to “I hear nothing” and 10 corresponding to “I hear perfectly”). Comparisons were accomplished using a t test for paired values.Results: A total of 32 comparative evaluations were performed. For cardiac auscultation, the value of the rating scale was 5.8 ± 1.5 and 6.4 ± 1.9, respectively, for the traditional and amplified stethoscope (P = .018). For lung sounds, quality of auscultation was estimated at 3.3 ± 2.4 for traditional stethoscope and at 3.7 ± 2.9 for amplified stethoscope (P = .15).Conclusions: Practicians in Falcon 50 are more able to hear cardiac sounds with an amplified than with a traditional stethoscope, whereas there is no significant difference concerning breath sounds auscultation.

Nontraumatic massive right-sided Bochdalek hernia in an adult: An unusual presentation - Corrected Proof

2010-08-05

Diaphragmatic hernias in adults usually pose a diagnostic challenge; the presentations are varied and range from acute abdominal pain with features of gut obstruction, pleuritic chest pain, breathlessness, to a pregnant woman with pain abdomen. The usual cause in adults is posttraumatic. Because of varied presentations, the diagnosis is often delayed.

A pilot study to develop a prediction instrument for endocarditis in injection drug users admitted with fever - Corrected Proof

2010-08-05

Abstract: Objective: Seeking to evaluate the feasibility of a prediction instrument for endocarditis in febrile injection drug users (IDUs), we determined (1) the frequency percentage of IDUs admitted with fever diagnosed with endocarditis and (2) whether individual or combinations of emergency department (ED) clinical criteria (patient history, physical examination findings, and laboratory tests) are associated with endocarditis in IDUs admitted to rule out endocarditis.Methods: The ED and inpatient charts of all IDUs with a diagnosis of rule out endocarditis admitted at 3 urban hospitals in 2006 were reviewed. Screening performance of individual criteria was determined, and the most sensitive combination of criteria was derived by classification tree analysis.Results: Of 236 IDUs admitted with fever, 20 (8.5%) were diagnosed with endocarditis. Lack of skin infection, tachycardia, hyponatremia, pneumonia on chest radiograph, history of endocarditis, thrombocytopenia, and heart murmur had the best screening performance. The classification tree–derived best criteria combination of tachycardia, lack of skin infection, and cardiac murmur had a sensitivity of 100% (95% confidence interval, 84%-100%) and negative predictive value of 100% (95% confidence interval, 88%-100%).Conclusions: Using ED clinical criteria, a multicenter prospective study to develop an instrument for endocarditis prediction in febrile IDUs is feasible, with an estimated target enrollment of 588 patients.

Etiology of septic arthritis in children: an update for the new millennium - Corrected Proof

Timothy P. Young, Lee Maas, Andrea W. Thorp, Lance Brown — 2010-08-05

Abstract: Objective: We sought to describe the causative organisms and joints involved in cases of pediatric septic arthritis in the post–Haemophilus influenzae type B and post-pneumococcal vaccine age and in the age of increasing infection with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA).Methods: This was a retrospective chart review of all children younger than 13 years presenting to our tertiary care pediatric emergency department between January 1, 2003, and December 31, 2007, with the diagnosis of septic arthritis. We reviewed the results of synovial fluid Gram stain and synovial fluid and blood culture. We defined septic arthritis as any of these 3 tests being positive for a known pathogen. We report patient characteristics, joint(s) involved, and organisms identified in these cases.Results: We describe 13 cases of septic arthritis. Fifteen joints were involved. The most common joint involved was the hip (6/15) followed by the elbow (3/15), knee (2/15), and ankle (2/15). The most common organism involved was methicillin-sensitive S aureus (6/13), followed by CA-MRSA (2/13) and Streptococcus pneumoniae (2/13).Conclusion: Our results support continued concern for involvement of the hip and knee in cases of pediatric septic arthritis and consideration of other joints such as the elbow and knee. Our data also suggest that empiric antibiotic coverage for CA-MRSA is indicated in cases of pediatric septic arthritis, as well as continued coverage for methicillin-sensitive S aureus and S pneumoniae.

Severe carbon monoxide poisoning complicated by hypothermia: a case report - Corrected Proof

Yoshito Kamijo, Toshimitsu Ide, Ayako Ide, Kazui Soma — 2010-08-05

It is proposed that the significant elevation of interleukin-6 (>400 pg/mL) in cerebrospinal fluid during the early phase of carbon monoxide poisoning may be a predictive biomarker for the development of delayed encephalopathy. A 52-year-old man presented to the emergency department with severe carbon monoxide poisoning. On arrival, the patient was comatose with decorticate rigidity (Glasgow Coma Scale, E1V1M3). His core body temperature, measured in the urinary bladder, was 32.4°C. Laboratory blood analysis revealed elevated CO-Hb (36.0%) and metabolic acidosis with elevated lactate (pH 7.081; base excess [BE], −19.2 mmol/L; HCO3, −9.8 mmol/L; lactate, 168.8 mg/dL). After treatment with hyperbaric oxygen and several different rewarming techniques, he became alert and his core body temperature increased to normal. Interleukin-6 in cerebrospinal fluid at 5.5 hours after his last exposure to carbon monoxide was significantly elevated (752 pg/mL). However, he did not develop delayed encephalopathy. In this case, hypothermia in the range of therapeutic hypothermia (32°C to 34°C) may have suppressed formation of reactive oxygen species and subsequent lipid peroxydation, preventing the development of delayed encephalopathy. Therapeutic hypothermia initiated soon after the last exposure to carbon monoxide may be an effective prophylactic method for preventing the development of delayed encephalopathy.

Severe chest pain during stress dobutamine echocardiogram in patient with patent epicardial coronary arteries - Corrected Proof

Hesham Hussein, Ayman El-Menyar, Emad Ahmed, Abdulrazzak Gehani — 2010-08-05

Dobutamine induced ST-segment elevation in the absence of obstructive coronary artery disease is a rare condition. We report a case of a 37-year-old man, a smoker, who developed severe chest pain associated with transient ST-segment elevation in anterolateral leads and significant segmental wall motion abnormalities during dobutamine stress echocardiography that was immediately relieved by sublingual nitrates without evidence of acute myocardial infarction. Coronary angiogram showed patent epicardial coronary arteries.

Extra scrotal spermatocele causing lower abdominal pain: a first case report - Corrected Proof

Denis J. Dollard, John B. Fobia — 2010-08-05

Lower quadrant abdominal pain is a common complaint evaluated in emergency departments (EDs).The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermatic cord, and polyorchidism. We report a case of extra scrotal spermatocele causing lower quadrant abdominal pain that was misdiagnosed as an inguinal hernia on several ED visits. Lower quadrant mass and pain caused by a spermatocele are unusual conditions. Upon the patient's third (ED) visit, the painful mass remained located in his right lower quadrant. The lower quadrant mass was movable on palpation and with pressure could be delivered into the superior aspect of the scrotum. The patient had an abdominal and pelvic computed tomography scan and lower quadrant ultrasound. The imaging studies revealed the mass to be a cystic structure. Surgical excision confirmed that the mass was a spermatocele. Differential diagnoses, diagnostic approaches, and treatment are discussed.

Do modern conflicts create different medical needs? - Corrected Proof

2010-08-05

Abstract: Purposes: This study involved analysis of (a) type of injuries and medical services used by military casualties in 3 conflicts and (b) medical needs of military and civilian casualties from the 2006 conflict.Basic Procedures: Military casualties from 3 conflicts and military and civilian casualties from the 2006 conflict were analyzed. Casualties were compared in relation to type of injury, length of stay (LOS), and operating room use (ORU).Main Findings: Hospital LOS of soldiers in many departments decreased while increasing in intensive care unit (ICU). Type of injuries sustained by civilians and military casualties differed significantly. More civilian casualties required admission to ICU. Civilian ORU was higher for orthopedic and otolaryngological procedures.Principal Conclusions: Civilians are less well protected during military conflicts, therefore, more susceptible to certain kind of injuries. Civilian and military casualties during conflicts have different medical needs. Civilians have higher morbidity than soldiers, which result in an increased need for treatment in ICU.

Bedside ultrasonography as a safe and effective tool to diagnose acute epiglottitis - Corrected Proof

2010-08-05

Acute epiglottitis is a true airway emergency in the emergency department (ED). The patient may appear very toxic and rapidly progress to respiratory distress and life-threatening condition. The inflammatory process includes not only epiglottis but also the rest of the supraglottic area including the vallecula, aryepiglottic folds, and arytenoids. Soft tissue swelling over this windpipe area can be very dramatic. The criterion standard of diagnosis is direct inspection of cherry red and swollen epiglottis by laryngoscopy in the operation room with immediate access to anesthetists or ear, nose, and throat specialists. However, before the patients are well prepared, the clinical condition may critically go downhill; and any intention to visualize the throat can result in severe and fatal airway spasm. Thumbprint sign on lateral radiography of neck is typical, but it may be extremely risky to let a patient leave the consulting room for the study if respiratory distress has developed. We demonstrate a safe and practical way to investigate the epiglottis by bedside ultrasonography to visualize the “alphabet P sign” in a longitudinal view through thyrohyoid membrane by emergency physician in the ED.

Sacral insufficiency fractures: an easily overlooked cause of back pain in the ED - Corrected Proof

John G. Galbraith, Joseph S. Butler, Simon P. Blake, Gemma Kelleher — 2010-08-05

Sacral insufficiency fractures are an important and treatable cause of severe back pain. Despite publication of several case reports since its original description in 1982, awareness of these injuries remains inadequate in emergency medicine. Most patients are elderly women presenting with intractable lower back pain. Postmenopausal osteoporosis is the most significant risk factor. Marked sacral tenderness is common. Neurologic impairment is rarely detectable. Routine radiography of the spine and pelvis is usually inconclusive. Computed tomography remains the diagnostic modality of choice. Treatment is usually conservative.

A 24-year-old woman with neck pain - Corrected Proof

Jonathan J. Marti, Joaquin F. Zalacain, Debra E. Houry, Alexander P. Isakov — 2010-08-05

Neck pain and stiffness is a common emergency department (ED) presentation and normal daily activities are usually the inciting cause. Most neck pain cases are benign in nature and can be relieved with rest and mild analgesics. Traumatic events and falls can cause severe neck injuries such as fractures, subluxation, vascular injuries, or paralysis. The following is an unusual case of atlantoaxial rotatory subluxation seen in our ED that initially presented as benign neck pain and torticollis.

Use of inhaled nitric oxide in the treatment of right ventricular myocardial infarction - Corrected Proof

2010-08-05

In 50% of acute left ventricular inferior-posterior wall myocardial infarction (MI), concomitant right ventricular MI (RVMI) has been reported, with a dramatic increased rate of mortality. We report the case of a woman with RVMI complicated by cardiogenic shock due to dissection of the right coronary artery. She was treated with liquid infusion, epinephrine, milrinone, and an intraaortic balloon pump, but clinical condition decreased. She was then intubated, and prolonged inhalation of nitric oxide (12-15 ppm) was added. Both clinical and hemodynamic parameters slowly improved with decrease of systemic (2513 ± 708 shifted to 1802 ± 369 dynes × s/cm5) and pulmonary vascular resistance (365 ± 183 to 309 ± 80 dynes × s/cm5) and central venous pressure (fell from 13 ± 4 mm Hg to 6 ± 4 mm Hg) and improvement of cardiac index (from 2.2 ± 0.5 to 3 ± 0.3 L/min per square meter). Inhalation of nitric oxide (iNO) withdrawal on day 7 caused a significant rebound pulmonary hypertension with decrease of cardiac output. Inhalation of nitric oxide was then reinstituted until day 8 and was finally gradually withdrawn without major hemodynamic variations. The patient was weaned from the ventilator on day 9 and was stable clinically and hemodynamically.

Using appendicitis scores in the pediatric ED - Corrected Proof

Katherine Mandeville, Tamara Pottker, Blake Bulloch — 2010-08-05

Abstract: Study Objective: The aims of the study were to prospectively evaluate the Alvarado and Samuel (pediatric appendicitis score [PAS]) appendicitis scoring systems in children and determine performance based on sex.Methods: Children with abdominal pain concerning for appendicitis were recruited. Nine parameters evaluated by the scores were documented before imaging/surgery consultation. Test characteristics were calculated on all patients and by sex.Results: Two hundred eighty-seven patients enrolled; median age was 9.8 years; and 155 (54%) were diagnosed with pathologic examination-confirmed appendicitis. Patients with appendicitis had mean PAS of 7.6, and those without had mean of 5.6 (P < .001). Patients with appendicitis had a mean Alvarado of 7.2, and those without had a mean of 5.2 (P < .001). In appendicitis patients, PAS cutoff of 6 or greater would give 137 correct diagnoses; sensitivity, 88%; specificity, 50%; and positive predictive value (PPV), 67%. An Alvarado cutoff of 7 or greater would give 118 correct diagnoses; sensitivity, 76%; specificity, 72%; and PPV, 76%. Both performed better in males than females.Conclusion: Regardless of sex, neither PAS nor Alvarado has adequate predictive values for sole use to diagnose appendicitis.

Wünderlich syndrome: an unusual cause of flank pain - Corrected Proof

2010-08-05

We report the case of a 75-year-old man with an infrarenal abdominal aortic aneurysm who presented to the ED complaining of flank pain. An urgent abdominal computed tomography showed the presence of abdominal aortic aneurysm and of perirenal and retroperitoneal hemorrhage independent of the aneurysm, but rather in relation to the left kidney, which also showed several simple cysts and angiomyolipomas. The patient remained stable and initial urgent surgical intervention was ruled out, while close vigilance was maintained. Spontaneous renal hemorrhage (Wünderlich syndrome) is a rare entity that can manifest with a life-threatening presentation of fulminant hypovolemic shock. Many causes have been attributed to this syndrome; the most frequent, tumoral, and within this class of tumors, renal adenocarcinoma and angiomyolipoma are most likely to be found. Renal cysts, blood dyscrasias, or anticoagulant and antiplatelet therapy are less frequent causes of renal hemorrhage. The typical clinical manifestation consists of pain in the flank, a palpable abdominal mass, and hypovolemic shock (Lenk's triad) which occurs in 20% to 30% of the cases. Computed tomography is the elective diagnostic method as it helps in identifying the cause. Management should be mainly expectant, although urgent surgical intervention (nephrectomy or evacuation of hematoma) may be required in cases of massive hemorrhage.

Acute episode of reversible blindness after an overdose of beta blockers and calcium channel antagonist - Corrected Proof

2010-08-05

Beta-blockers or calcium channel blockers are major cardiovascular drugs. Both have similar physiologic and toxic effects, and act synergistically. These include refractory bradycardia, heart block, and hypotension. A compromised perfusion of the optic nerve head leads to ischemic optic neuropathy. Two cases of combined beta-blocker and calcium channel blocker overdose causing a previously unknown complication of posterior ischemic optic neuropathy are presented to create awareness so as to make an early recognition of the toxic etiologies, and to introduce appropriate therapy and minimize morbidity.

A case of closed total dislocation of talus and literature review - Corrected Proof

2010-08-05

Total dislocation of talus is a rare and serious injury. The course in most cases is dominated by osteonecrosis, which explains the poor prognosis of this condition. Authors report a case of closed total dislocation of talus in its anterolateral variety. Reduction of dislocation had been performed in emergency by external manipulation. At the last follow-up, the ankle was painless, stable with a satisfactory mobility, and without radiologic signs of necrosis.

Idiopathic purpura fulminans - Corrected Proof

Firat Bektas, Secgin Soyuncu — 2010-08-05

A 45-year-old man presented to the ED with a history of bruising rush on both his breast areas initiated 2 days ago and which increased rapidly. The vital signs and physical examination result of the patient were normal except for blue-black hemorrhagic and bruised lesions with a surrounding erythematous border on both his breast areas. Prothrombin and activated prothrombin time and international normalized ratio (1.2 [upper level is 1.2]), protein C, protein S, and antithrombine III levels and other laboratory parameters were also normal. He was admitted to the hospital for treatment. We were presented with a case of idiopathic purpura fulminans which is rarely diagnosed in the ED.

Methadone-induced torsade de pointes - Corrected Proof

Sean Patrick Nordt, Jeffrey Zilberstein, Barry Gold — 2010-08-05

Torsade de pointes is a rare but life-threatening ventricular dysrhythmia that has been associated with numerous medications. We present a case of polymorphic ventricular tachycardia in a 55-year-old man on methadone. The patient's QTc interval normalized after discontinuation of the methadone. Emergency physicians should be aware of this potential adverse effect from methadone.

Thrombolysis associated with LUCAS (Lund University Cardiopulmonary Assist System) as treatment of valve thrombosis resulting in cardiac arrest - Corrected Proof

2010-08-05

Thromboembolic complications remain a frequent cause of morbidity and mortality in patients with a mechanical prosthetic heart valve. We report the case of a 57-year-old female patient admitted for acute respiratory distress. A thrombosis of the St Jude mitral valve was confirmed by transesophageal echocardiography. Surgery was planed, but brutal deterioration of her hemodynamic parameters and cardiac arrest prompted emergency thrombolysis. A LUCAS (Lund University Cardiopulmonary Assist System) chest compression device was used. Rapid recovery of valve mobility was obtained. Hypothesis of this rapid recovery and safety of LUCAS in this setting are discussed.

Hypertension in the ED: a multifaceted intervention to change provider practice - Corrected Proof

Juliane Bohan, Lynne Fullerton, Barbara Oakland, Jill Oldewage — 2010-08-05

Abstract: This project measured the effect of a multifaceted intervention on health care provider identification and treatment of undiagnosed hypertensive patients. The intervention comprised provider education, audit, and feedback. The primary outcomes were pre-/postintervention differences in the proportion of patients presenting with elevated blood pressure who were (1) identified, (2) given blood pressure measurements, (3) counseled regarding behavior change, (4) prescribed medications, and (5) advised of the need for follow-up. These 5 behaviors were selected based on the recommendations in the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.Rates of all 5 outcomes improved significantly after the intervention, with prevalence differences ranging from 5% to 25%. However, despite increases, rates for each behavior remained low. At no point during the study were all 5 practitioner behaviors documented for an individual patient.In conclusion, while an intervention composed of education and practitioner audit and feedback improved practitioner behaviors in treating patients with elevated blood pressure, additional interventions are needed to bring practitioner behaviors up to the level of JACHO standards.

Low yield of ED magnetic resonance imaging for suspected epidural abscess - Corrected Proof

Mazen El Sayed, Michael D. Witting — 2010-08-05

Abstract: Purpose: The aim of this study was to estimate the yield of emergency department (ED) magnetic resonance imaging (MRI) in detecting spinal epidural abscess (SEA) and to identify clinical factors predicting positive MRI results.Basic Procedure: We examined a cohort of patients who underwent MRI to rule out SEA, followed by a nested case-control comparison of those with positive results and a sample with negative results. A positive result was defined as osteomyelitis, discitis, or SEA. Predictor variables included temperature, presenting complaint, drug abuse status, history of SEA or back surgery, midline back tenderness, neurologic deficit, MRI level, mean white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level.Main Findings: Fourteen of the 120 available MRIs were excluded; 7 (6.6%) of the remaining 106 were positive. Temperature was 1.1°C higher in cases than controls (95% CI, 0.6-1.7).Conclusion: Emergency department MRI for suspected SEA has a low yield. Clinical guidelines are needed to improve efficiency.