American Journal of Emergency Medicine

Use of a limited lights and siren protocol in the prehospital setting vs standard usage

2011-05-13

Abstract: Objective: Our objective was to determine if implementing a standard lights and sirens (L&S) protocol would reduce their use and if this had any effect on patient disposition.Methods: In a prospective cohort study, we trained emergency medical services (EMS) personnel from 4 towns in an L&S protocol and enrolled control personnel from 4 addition towns that were not using the protocol. We compare the use of L&S between them over a 6-month period. Our protocol restricted the usage of L&S to patients who had maladies requiring expedited transport. Emergency medical services personnel from the control towns had no such restrictions and were not aware that we were tracking their usage of L&S. We also considered if patient disposition was affected by the judicious usage of L&S.Results: Prehospital EMS personnel who were trained in an L&S protocol were 5.6 times less likely to use L&S when compared with those not trained. Of the 808 patients transported by both types of workers, no difference in patient disposition was observed.Conclusions: Our protocol significantly reduced the use of L&S. Judicious use of L&S has significant implications for transport safety. By allowing for selective transport with L&S usage, we observed no impact in patient disposition.

Factors associated with law enforcement–related use-of-force injury

Edward M. Castillo, Nitin Prabhakar, Bethi Luu — 2011-03-16

Abstract: Objective: Use-of-force (UOF) techniques are used by law enforcement to gain control of noncompliant subjects. The purpose of this study was to assess factors associated with subject and deputy injuries during law enforcement UOF.Methods: This is a retrospective study of nonlethal UOF events from January to June 2009 by a single law enforcement agency serving a population of 3 million. A standard data collection tool, which included basic demographic data, the type of force used, subject response, and if there were any injuries to the subject or deputies involved, was used by deputies for each UOF event. Descriptive statistics were used to describe the specific subject and incident details. Univariate and multivariate analysis was used to identify factors potentially associated with subject and deputy injuries.Results: There were 1174 UOF incidents recorded during the study period. A total of 282 incidents (24%) involved no physical force, 135 (11.5%) involved less lethal methods, 620 (52.8%) involved other physical restraint methods, and 137 (11.7%) involved both less lethal and other physical methods. Factors with the largest independent associations with subject injury were physical resistance by the subject (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.49-4.74) and force used to prevent a violent felony (OR, 2.15; 95% CI, 1.24-3.71). When the subject had a weapon (OR, 4.15; 95% CI, 1.53-11.23) and physical resistance by the subject (OR, 4.15; 95% CI, 1.24-13.94) had the largest associations with deputy injury.Conclusions: This study identifies situational characteristics potentially associated with subject and deputy injuries during UOF events.

Operational and financial impact of physician screening in the ED

2011-03-21

Abstract: Background: Physician screening is one of many front-end interventions being implemented to improve emergency department (ED) efficiency.Study objective: We aimed to quantify the operational and financial impact of this intervention at an urban tertiary academic center.Methods: We conducted a 2-year before-after analysis of a physician screening system at an urban tertiary academic center with 90 000 annual visits. Financial impact consisted of the ED and inpatient revenue generated from the incremental capacity and the reduction in left without being seen (LWBS) rates. The ED and inpatient margin contribution as well as capital expenditure were based on available published data. We summarized the financial impact using net present value of future cash flows performing sensitivity analysis on the assumptions. Operational outcome measures were ED length of stay and percentage of LWBS.Results: During the first year, we estimate the contribution margin of the screening system to be $2.71 million and the incremental operational cost to be $1.86 million. Estimated capital expenditure for the system was $1 200 000. The NPV of this investment was $2.82 million, and time to break even from the initial investment was 13 months. Operationally, despite a 16.7% increase in patient volume and no decrease in boarding hours, there was a 7.4% decrease in ED length of stay and a reduction in LWBS from 3.3% to 1.8%.Conclusions: In addition to improving operational measures, the implementation of a physician screening program in the ED allowed for an incremental increase in patient care capacity leading to an overall positive financial impact.

Is urinary 5-hydroxyindoleacetic acid helpful for early diagnosis of acute appendicitis?

2011-03-30

Abstract: Objective: Acute appendicitis is the most common abdominal emergency in children and young adults. There are a lot of serotonin-containing cells in the appendix, which release serotonin into the bloodstream in response to inflammation. Consequently, serotonin is converted to 5-hydroxyindoleacetic acid (5-HIAA) and secreted into the urine. On this basis, urinary 5-HIAA could be a marker for acute appendicitis. In this study, we investigated the value of 5-HIAA levels in spot urine in the diagnosis of acute appendicitis.Methods: The urinary 5-HIAA was measured by an enzyme-linked immunosorbent assay in the spot urine of 70 patients who presented to the emergency department with a clinical picture of acute appendicitis. Urine concentration results were correlated to final histopathologic reports, and the diagnostic value of this factor was measured.Results: Diagnosis of appendicitis was confirmed by histopathologic reports in 59 of 70 patients with presumptive diagnosis of appendicitis. Considering 5.25 mg/L as the cutoff point for urinary 5-HIAA, 28 patients had high urinary 5-HIAA levels, whereas 42 patients had values within reference range. The sensitivity and specificity of this test was 44% and 81%, respectively.Conclusions: The measurement of urinary 5-HIAA levels is not an ideal diagnostic tool for ruling out or determination of acute appendicitis.

Ischemic-appearing electrocardiographic changes predict myocardial injury in patients with intracerebral hemorrhage

2011-03-30

Abstract: Objectives: Myocardial injury is common among patients with intracerebral hemorrhage (ICH). However, it is challenging for emergency physicians to recognize acute myocardial injury in this population, as electrocardiographic (ECG) abnormalities are common in this setting. Our objective is to examine whether ischemic-appearing ECG changes predict subsequent myocardial injury in the context of ICH.Methods: Consecutive patients with primary ICH presenting to a single academic center were prospectively enrolled. Electrocardiograms were retrospectively reviewed by 3 independent readers. Anatomical areas of ischemia were defined as I and aVL; II, III, and aVF; V1 to V4; and V5 and V6. Medical record review identified myocardial injury, defined as troponin I or T elevation (cutoff 1.5 and 0.1 ng/mL, respectively), within 30 days.Results: Between 1998 and 2004, 218 patients presented directly to our emergency department and did not have a do-not-resuscitate/do-not-intubate order; arrival ECGs and troponin levels were available for 206 patients. Ischemic-appearing changes were noted in 41% of patients, and myocardial injury was noted in 12% of patients. Ischemic-appearing changes were more common in patients with subsequent injury (64% vs 37%; P = .02). After multivariable analysis controlling for age and cardiac risk factors, ischemic-appearing ECG changes independently predicted myocardial injury (odds ratio, 3.2; 95% confidence interval, 1.3-8.2). In an exploratory analysis, ischemic-appearing ECG changes in leads I and aVL as well as V5 and V6 were more specific for myocardial injury (P = .002 and P = .03, respectively).Conclusion: In conclusion, although a range of ECG abnormalities can occur after ICH, the finding of ischemic-appearing changes in an anatomical distribution can help predict which patients are having true myocardial injury.

Prospective study of the elder self-neglect and ED use in a community population

XinQi Dong, Melissa A. Simon, Denis Evans — 2011-03-16

Abstract: Purpose: This study aims to quantify the relation between elder self-neglect and rate of emergency department utilization in a community-dwelling population.Methods: A prospective population-based study is conducted in a geographically defined community in Chicago of community-dwelling older adults who participated in the Chicago Health and Aging Project. Of the 6864 participants in the Chicago Health and Aging Project, 1165 participants were reported to social services agency for suspected elder self-neglect. The primary predictor was elder self-neglect reported to social services agency. The outcome of interest was the annual rate of emergency department utilization obtained from the Center for Medicare and Medicaid Services. Poisson regression models were used to assess these longitudinal relationships.Results: The average annual rate of emergency department visits for those without elder self-neglect was 0.6 (1.3), and for those with reported elder self-neglect, it was 1.9 (3.4). After adjusting for sociodemographics, socioeconomic variables, medical conditions, and cognitive and physical function, older people who self-neglect had significantly higher rates of emergency department utilization (rate ratio, 1.42; 95% confidence interval, 1.29-1.58). Greater self-neglect severity (mild: standardized parameter estimate [PE], 0.27; standard error [SE], 0.04; P < .001; moderate: PE, 0.41; SE, 0.03; P < .001; severe: PE, 0.55; SE, 0.09; P < .001) was associated with increased rates of emergency department utilization, after considering the same confounders.Conclusion: Elder self-neglect was associated with increased rates of emergency department utilization in this community population. Greater self-neglect severity was associated with a greater increase in the rate of emergency department utilization.

Pitfalls in using serum C-reactive protein to predict bacteremia in febrile adults in the ED

2011-04-25

Abstract: Objectives: The diagnostic performance of serum C-reactive protein (CRP) in prediction of bacteremia among febrile patients visiting an emergency department (ED) was analyzed.Methods: During randomly selected 96 days between August 2006 and July 2007, a prospective study of febrile adults visiting the ED of a medical center was conducted to analyze the clinical characters associated with bacteremia.Results: Of the total 454 febrile adults enrolled, their mean age was 54.1 years, and 232 (54.6%) were women. Major comorbidities included cardiovascular disease (137 patients, or 30.1%) and diabetes mellitus (105, or 23.1%). Seventy-four patients (16.2%) had true bloodstream infections with the predominance of monomicrobial gram-negative bacteremia in 49 patients (10.7%). Four risk factors, including low platelet count (<100 000/mm3; odds ratio [OR], 4.19; 95% confidence interval [CI], 1.85-9.47; P = .001), high blood urea nitrogen (>20 mg/dL; OR, 4.61; 95% CI, 2.56-8.31; P < .001), high fever (>39.0°C; OR, 3.67; 95% CI, 2.05-6.59; P < .001), and high Pittsburg bacteremia scores (≧4 points; OR, 2.95; 95% CI, 1.01-8.57; P = .04) were independently associated with bacteremic episodes. Of note, high CRP (>150 mg/dL; OR, 1.75; 95% CI, 0.73-3.99; P = .21) was not an independent risk factor. In further analysis, the difference of serum CRP levels between bacteremic and nonbacteremic adults was significant only when the period from fever onset to ED arrival was more than 12 hours.Conclusions: The CRP level was not reliable to distinguish the bacteremia from nonbacteremic infection, whereas duration after fever onset was less than 12 hours. Clinicians must consider the history of fever onset to improve the accuracy of early prediction of serum CRP before the microbiological results of blood cultures is available.

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

2011-05-13

Abstract: Background: With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma.Methods: Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out.Results: During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected.Conclusion: For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.

Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma

James F. Holmes, John P. McGahan, David H. Wisner — 2011-06-06

Abstract: Objective: The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary.Methods: We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified.Results: Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (−) of 0.034 (0.017-0.068).Conclusion: Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases.

Incidence and predictors of ventricular arrhythmias after ST-segment elevation myocardial infarction

2011-05-13

Abstract: Background: Sustained ventricular arrhythmias (VA) complicate 7% to 20% of acute myocardial infarctions. We hypothesized that primary angioplasty (percutaneous coronary intervention [PCI]) and contemporary medical treatment will result in a lower incidence of VA and shorten the time frame of their occurrence. Thus, an electrocardiographic monitoring period of 24 hours should be sufficient to detect more than 95% of all malignant VA.Methods: We continuously monitored all patients with ST-segment elevation myocardial infarction (STEMI) for 48 hours.Results: Of the 510 patients who underwent PCI for STEMI, 24 (4.7%) developed sustained VA. Sixty percent of sustained VA occurred during the first 24 hours; and 92%, during the first 48 hours. In univariate analysis, heart rate greater than 100 beats per minute, Thrombolysis in Myocardial Infarction flow grade less than 3, elevated creatinine (≥1 mg/dL), elevated C-reactive protein (≥0.8 mg/dL), higher white blood cell count (≥12 × 103/μL), use of diuretics, and lower hematocrit (≤39%) were associated with an increased risk of VA. Symptom-onset-to-balloon time of 4 hours or more in patients with postprocedural Thrombolysis in Myocardial Infarction 3 flow, treatment with β-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins were associated with a reduced risk of VA. After multivariate adjustment, independent predictors of sustained VA included total white blood cell count of 12 × 103/μL or more, hematocrit of 39% or less, and lack of β-blocker medication.Conclusions: In this study, we could demonstrate that primary PCI results in a lower incidence of VA compared with data from the literature but did not shorten the time frame of VA occurrence. Thus, an electrocardiographic monitoring period for VA of 48 hours should be performed in patients with STEMI.

ED patients with vertigo: can we identify clinical factors associated with acute stroke?

2011-04-29

Abstract: Background: Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability.Objective: The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo.Methods: We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke.Results: There were 325 eligible patients; 131 were ED patients. Patients were 57 (±18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke.Conclusions: This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population.

Tumescent technique in digits: a subcutaneous single-injection digital block

Yuan-Sheng Tzeng, Shyi-Gen Chen — 2011-03-30

Abstract: Background: A modified subcutaneous single-injection approach to achieve digital block using a tumescent technique is described.Method: A convenient sample of patients requiring digital anesthesia for minor surgical procedures on the fingers or thumb in the emergency and plastic departments were enrolled into the study. Digital nerve block was performed by injecting 1% lidocaine into the volar subcutaneous space at the proximal digit to create a firm, turgid feel to the tissue, the so-called tumescent state. The volume of anesthetic was based on the size of the digit. All nerve blocks were performed by 1 surgeon. Successful digital anesthesia was defined as complete loss of pinprick sensation on both the dorsal and volar aspects of the digit and the ability to complete the anticipated minor surgical procedure without pain. All patients were followed for 1 month to assess for adverse events.Result: Between August 2009 and January 2011, 123 patients (123 digits) requiring digital anesthesia were enrolled into the study. Thirty-nine (32%) were volar lesions, and 84 (68%) were dorsal lesions. The tumescent technique single-injection digital block was successful in all digits. No adverse events were reported.Conclusion: The tumescent technique in digits to achieve a single-injection digital nerve block is an easy, safe and effective method for digital anesthesia. These data confirm the applicability of the tumescent technique in digits for patients with finger and thumb injuries or tumors that require minor surgical procedures.

Implications of 25% to 50% coronary stenosis with cardiac computed tomographic angiography in ED patients

2011-04-29

Abstract: Objective: The aim of this study was to determine if patients presenting with symptoms of acute coronary syndrome and found to have 25% to 50% diameter reduction with coronary computed tomographic angiography (CCTA) are likely to benefit from further diagnostic testing.Methods: A registry study of 213 subjects (median age, 51 years; 53% women) with symptoms concerning for possible acute coronary syndrome with low-risk features found to have 25% to 50% maximal diameter stenosis on CCTA was performed at 2 academic medical centers. The analysis was approved by an institutional review board and was conducted with waiver of consent. The potential contribution of additional testing was determined by measuring the major adverse cardiac events (MACEs) from presentation through 30 days. The MACEs included myocardial infarction, coronary revascularization, unstable angina, and cardiovascular death. Sample size calculations were predicated on a 0% MACE rate leading to upper bounds of a 2-sided exact 95% confidence interval less than 2%.Results: Thrombolysis in myocardial infarction risk score of less than 2 was present in 92% subjects, 70% (150 of 213) had 2 or more serial cardiac markers performed, and 40% (87 of 213) had stress testing or cardiac catheterization. The MACEs occurred in 1 (0.5%) of 213 subjects (95% confidence interval, 0%-2.6%) and was identified by an elevation of serial cardiac markers during the index hospitalization. No patients experienced cardiovascular death or required revascularization.Conclusions: In patients with emergent low-risk chest pain and 25% to 50% diameter coronary stenosis by CCTA, the rate of near-term MACE is very low. Serial cardiac markers may be beneficial in this subgroup. Routine provocative testing is unlikely to be beneficial during the index visit.

The orthopedic literature 2010

Michael C. Bond, Daniel L. Lemkin, William J. Brady — 2011-04-25

A. Vander Have KL, Perdue AM, Caird MS, Farley FA. Operative versus nonoperative treatment of midshaft clavicle fractures in adolescents. J Pediatr Orthop 2010;30:307-312. In 1960, Neer published his experience with 2235 patients with clavicle fractures. In this series, the nonunion rate associated with medical treatment was 0.13%, compared with 4.6% among the 45 patients who underwent surgery. Based on that report, medical students have been taught that most fractures should be treated nonoperatively. More recent articles that were included in our 2009 edition of orthopedic summaries presented evidence that nonoperative treatment in adults results in higher rates of malunion, nonunion, chronic pain, and disability than operative repair . The cohort of Neer included a large number of children and adolescents, who typically heal well without sequelae. The article by Vander Have et al highlights that younger children are different from adolescents, in that children have more effective “remodeling with continued growth.” Adolescents nearing maturity may benefit from surgical repair.

The cardiac literature 2010

Amal Mattu, Michael C. Bond, Semhar Z. Tewelde, William J. Brady — 2011-05-02

A. Pokorna M, Necas E, Kratochvil J, et al. A sudden increase in partial pressure end-tidal carbon dioxide (PETCO2) at the moment of return of spontaneous circulation. J Emerg Med 2010;38:614-621.

Another use of the ultrasound-guided transversus abdominis plane block in the ED

2012-02-10

We read with interest the article published by Herring et al , describing the interest of the transversus abdominis plane (TAP) block for analgesia in emergency situations. We describe another interest of the technique. We used the TAP block for a woman with acute hyperalgesic pancreatitis for analgesia in a clinical situation with opiate resistance.

QT interval—what is normal? Comment on “Single-dose ziprasidone associated with QT interval prolongation”

Hossein Sanaei-Zadeh — 2012-02-10

I read with interest the case presented by Witsil et al recently published in the American Journal of Emergency Medicine. They have reported a 47-year-old male patient who had presented to the emergency department (ED) from a detoxification center with suicidal ideation. He had a history of depression and substance abuse (cocaine). His physical examination was unremarkable, except for agitation. His baseline electrocardiogram (ECG) demonstrated a normal sinus rhythm and a QT/QTc of 484/475 milliseconds at a pulse of 58 beats per minute. The patient was given 20 mg intramuscular ziprasidone for agitation. He developed palpitations and weakness 45 minutes after receiving ziprasidone. His QT interval was prolonged on ECG and returned to baseline after 72 hours. They concluded that performing an ECG before ziprasidone dosing should be considered. It seems that the point that the authors have missed is that the patient has had QT/QTc prolongation since ED presentation , the reason of which is not clear. Despite the patient denial, it seems impossible that a patient who had been hospitalized in detoxification center has not been on any medication. Although the patient has not developed torsade de pointes during the hospital course (even after the administration of ziprasidone), his QT interval considering his heart rate at presentation has made him prone to torsade de pointes based on either the nomogram recently developed for the arrhythmogenic risk assessment of drug-induced QT prolongation or his QTc duration (at baseline, QT was on “at risk" line of the nomogram and QTc was > 450 ms) . The authors have suggested to perform an ECG before the administration of ziprasidone while they have interestingly not benefited from ECG performance in their own patient. As the authors themselves have mentioned, ziprasidone is an atypical antipsychotic associated with QTc prolongation even in therapeutic doses .

Atropine dosage in patients with severe organophosphate pesticide poisoning

Hossein Sanaei-Zadeh — 2012-02-10

I would like to address the article published in the February 2011 issue on pages 244.e1-244.e2, titled “The efficacy of obidoxime 72 hours after intoxication by organophosphates.” The authors have presented a patient intoxicated by organophosphate O, S-dimethyl phosphoramidothioate who had presented with typical cholinergic signs and symptoms. The patient had partially been treated by atropine, administration of activated charcoal, ventilator support, and general measures at presentation, that is, 24 hours before the initiation of the management by the authors. At the time of intensive care unit admission, he still had miotic pupils without reflexes, sialorrhea, bronchorrhea, and sibilance. According to the authors, the patient was treated with a continuous infusion of atropine with at least 300 vials of it within the period of hospital stay. Seventy-two hours after his acute intoxication, obidoxime was supplied and given with the dose of 250 mg every 8 hours for 5 doses. After that, the patient's condition got better, and his muscarinic and nicotinic signs resolved.

A mission statement for Emergency Medicine

Scott A. Syverud — 2012-02-10

Bring us your ill, your injured, your wheezing children yearning to breath free.Send us the sickest, the traumatized, to see.To heal, to help, relieve, restore.We lift our lamp, Healthcare's front door.

Noninvasive Doppler ultrasound cardiac output monitor for the differential diagnosis of shock

2012-03-02

The evaluation of a patient in clinical shock or hypotensive states is often challenging. Recently, our emergency department (ED) has started using a noninvasive cardiac output Doppler ultrasound monitor to assist in the rapid diagnosis of the underlying cause of shock (or hypotensive states, suspected shock) . Its use is illustrated in the following 2 cases.

Hematogenous septic arthritis of the hip in adult patients

2012-02-10

Septic arthritis of the hip is a severe infection and relatively infrequent in the general population. The aim of the present study was to review our experience in septic arthritis of naive hips for the last 18 years.

Comment on “A novel approach to confirming nasogastric tube placement in the ED”

Franck Petitpas, Thomas Kerforne, Corentin Lacroix, Olivier Mimoz — 2012-03-02

We read with interest the recently published case report by Nguyen et al regarding a novel approach to confirming nasogastric tube placement in the emergency department (ED) using ultrasound of the soft tissues of the neck to visualize the tube in esophagus as well as in the epigastrum to confirm its placement in the stomach.

Posterior urethral valves diagnosed by bedside ultrasound in the ED

Joshua Schecter, Jennifer H. Chao — 2011-03-16

Posterior urethral valves are the most common cause of urinary obstruction in male children. Presentations of posterior urethral valves beyond the neonatal period include urinary tract infection, abdominal mass, renal failure, diminished urinary stream, crying during micturition, incontinence, dysuria, hematuria, or failure to thrive. Early diagnosis is imperative because early surgical relief of the obstruction is believed to help prevent the progression to end stage renal disease.

Unresponsive ventricular tachycardia associated with aluminum phosphide poisoning

Amar P. Jadhav, Maein B. Nusair, Apekshe Ingole, Martin A. Alpert — 2011-03-16

Inhalation or ingestion of aluminum phosphide (AP) generates phosphine gas on exposure to moisture, which, in turn, produces widespread organ toxicity primarily involving the lungs, heart, liver, and kidneys. Cardiac manifestations of AP poisoning include toxic myocarditis, refractory heart failure, bradyarrhythmias, and tachyarrhythmias including ventricular tachycardia (VT). A 19-year-old depressed male farm worker ingested ten 500-mg tablets of Celphos in a suicide attempt. Each Celphos tablet contains 56% AP. Over the course of 10 hours, the patient developed heart failure and respiratory failure associated with a rise in serum troponin level to 12.7 ng/mL. Serum electrolytes (including magnesium) and serum creatinine levels were normal throughout. His course was further complicated by acidemia and hypotension. These hemodynamic and metabolic abnormalities were initially corrected by assisted ventilation and continuous veno-venous hemofiltration. However, he developed hemodynamically stable sustained monomorphic VT, which proved unresponsive to treatment with intravenous magnesium sulfate and intravenous amiodarone therapy. After a decline in blood pressure, 6 attempts at electrocardioversion failed to restore sinus rhythm, and he died. Postmortem histologic examination of myocardium showed contraction band necrosis, early coagulation necrosis, edema, hemorrhage, and pyknosis of cardiac myocyte nuclei. Ventricular tachycardia associated with AP poisoning has been successfully treated with magnesium sulfate, amiodarone, and electrocardioversion. This case report documents failure of all 3 of these therapeutic modalities.

A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage

Terasumi Keiko, Youichi Yanagawa, Susumu Isoda — 2011-03-16

An 81-year-old woman became unconsciousness after complaining of a backache, and then, an ambulance was called. She was suspected to have an aortic dissection by the emergency medical technicians and was transferred to our department. On arrival, she was in shock. Emergency cardiac ultrasound disclosed good wall motion with cardiac tamponade but no complication of aortic regurgitation. Computed tomography of the trunk revealed a type A aortic dissection with cardiac tamponade. During performance of pericardial drainage, she lapsed into cardiopulmonary arrest. Immediately after sterilization of the patient's upper body with compression of the chest wall, we performed a thoracotomy and dissolved the cardiac tamponade by pericardiotomy and obtained her spontaneous circulation. Fortunately, blood discharge was ceased immediately after controlling her blood pressure aggressively. As she complicated pneumonitis, conservative therapy was performed. Her physical condition gradually improved, and she finally could feed herself and communicate.

Point-of-care ultrasound diagnosis of acute Achilles tendon rupture in the ED

Srikar Adhikari, Jared Marx, Todd Crum — 2011-03-16

Patients with acute Achilles tendon injuries from sport-related activities are frequently seen in the emergency department (ED). Missed or delayed diagnosis of an Achilles tendon rupture can result in significant patient morbidity. However, the diagnosis of an Achilles tendon rupture is not always clear clinically. Physical examination maneuvers to assess for a tendon injury can be limited by pain and soft tissue swelling. Ultrasound has been shown to be very sensitive in detecting an Achilles tendon rupture. We report a case of a 39-year-old woman who presented to the ED with severe left ankle and leg pain. Her physical examination was limited by pain. However, a point-of-care ultrasound examination helped in making a prompt and accurate diagnosis of acute Achilles tendon rupture. This case demonstrates that point-of-care ultrasound can be a useful diagnostic tool in the assessment of patients with suspected Achilles tendon rupture, particularly when the physical examination is limited.

Rhabdomyolysis associated with kava ingestion

Ryan Bodkin, Sandra Schneider, Donna Rekkerth, Linda Spillane, Michael Kamali — 2011-04-04

We report a case of rhabdomyolysis temporally related to the ingestion of a large amount of kava. Kava is a naturally occurring plant used in the United States and elsewhere in the world for its sedative properties. A previous case report also related rhabdomyolysis to the ingestion of kava. It is not clear whether this is an action of the kava itself, perhaps, due to its action on voltage ion channels or, perhaps, due to an adulterant in the product. Our patient developed peak creatine phosphokinase levels in excess of 30 000 U/L but had no significant renal damage.

Successful electrical cardioversion in a massive concentric hypertrophic cardiomyopathy with atrial fibrillation

Servet Altay, Huseyin Altug Cakmak, Serhan Ozcan, Erkan Ilhan, Betul Erer — 2011-04-25

A 59-year-old man with a known history of nonobstructive hypertrophic cardiomyopathy and chronic atrial fibrillation was admitted to our clinic with weakness, palpitation, and exertional dyspnea. Electrocardiogram showed atrial fibrillation with high ventricular rate (120 beats per minute), intraventricular conduction delay, and left ventricular (LV) hypertrophy with ST-segment depression and inverted T waves. A transthoracic echocardiogram showed massive LV concentric hypertrophy. Although there was no gradient increase in the LV outflow tract, marked turbulent flow was seen in midventricular region by colored Doppler echocardiography. On the fourth day of admission, transesophageal echocardiography was done and showed no thrombus in the left atrium. Electrical cardioversion with 100 J was applied to the patient, and atrial fibrillation was returned to sinus rhythm. His control Doppler echocardiogram revealed peak systolic resting gradient of 54 mm Hg, with an increase to 84 mm Hg at Valsalva maneuver at the LV outflow. Cardiac magnetic resonance showed concentric LV hypertrophy with a 35-mm thickness in diastole, mild scar tissue in LV anterior wall midapical segments, and right ventricle wall thickness with a 10 mm in diastole. There was no bradycardia or tachycardia in 24-hour Holter and exercise electrocardiographic testing.

Atraumatic neck pain and rigidity: a case of calcific retropharyngeal tendonitis

J.L. Martindale, E.L. Senecal — 2011-04-25

Neck pain with associated rigidity is a concerning clinical presentation that emergency physicians encounter regularly. We present the case of a 58-year-old man with acute neck pain, worsened by movement and swallowing, that was found to be secondary to acute calcific retropharyngeal tendonitis. Patients with severe neck pain, neck stiffness, and odynophagia may have this condition. The diagnosis can be confirmed with imaging, and response to conservative treatment is often dramatic.

Recurrent choking as a presenting feature of aortic arch aneurysm

Ken-Hing Tan, Sun-Li Chou, Shih-Yu Ko — 2011-03-30

Aortic arch aneurysm occurs more commonly in the aging population. Rapid expansion and symptomatic patients should undergo aneurysm resection regardless of size. An 87-year-old man was brought to our emergency department because of choking on food during his dinner. The patient did not have hoarseness, dysarthria, dysphagia, as well as other neurologic symptoms. He was finally found to have an aortic arch aneurysm. Swallowing is complex neuromuscular activity consisting essentially of 3 phases: oral, pharyngeal, and esophageal. The pharyngeal phase was mainly mediated by the pharyngeal plexuses of both the glossopharyngeal and vagus nerves. Uncoordinated movement of the pharyngeal muscles because of a stretch of the left vagus nerve or its plexus by an enlarging aneurysm may be the possible mechanism of choking in this patient.

Concurrent pulmonary embolism and acute coronary syndrome with dynamic electrocardiographic changes

Ahmet Yildiz, Cem Bostan, Fatih Akin, Alev Arat Ozkan, Tevfik Gurmen — 2011-03-30

Concomitant occurrence of pulmonary embolism and acute coronary syndrome is rare. The early diagnosis and treatment of acute coronary syndrome with right ventricular myocardial ischemia during acute pulmonary embolism (APE) are crucial. The irreversible right ventricular myocardial dysfunction is a major risk factor for mortality from APE. In this case report, we present a 66-year-old female patient with APE who had a significant right coronary artery (RCA) lesion, which was successfully treated with angioplasty and stent implantation.

Posterior vitreal detachment in decompression illness—case report and discussion

2011-04-29

We report a case of a healthy leisure diver presenting with simultaneous unilateral posterior vitreous detachment and decompression illness. The literature is reviewed for both conditions. There are no known publications associating these 2 entities and leads us to propose that nitrogen bubble formation could have contributed to the etiology of vitreal separation from the retina.

Acute myocardial infarction in a 56-year-old female patient treated with sulfasalazine

2011-04-25

Drug rash, eosinophilia, and systemic symptoms (DRESS) syndrome represents one pattern of the cutaneous involvement in type IV hypersensitivity reaction to drugs. It is a severe, delayed, idiosyncratic reaction presented as rash with fever, lymphadenopathy, and visceral involvement. There are several reported cases of sulfasalazine-induced DRESS syndrome, but myocardial involvement was rare. High index of suspicion is needed in every patient receiving these drugs for prompt diagnosis and early management. We report a case of a 56-year-old woman treated with sulfasalazine for ankylosing spondylitis for 3 weeks, which was discontinued after development of DRESS syndrome. Despite treating her with high dose of steroid and cyclosporine, her symptoms persisted, and ultimately, she developed toxic myocarditis with a misleading presentation of acute ST-elevated myocardial infarction. The diagnosis was made based on postmortem histopathologic finding.

Extreme QT prolongation during therapeutic hypothermia after cardiac arrest due to long QT syndrome

2011-04-04

During therapeutic hypothermia, QT interval is prolonged. In patients with congenital long QT syndrome (LQTs), a longer QT interval was associated with significantly increased risk of cardiac arrest (CA). Therefore, therapeutic hypothermia may have proarrhythmic effects in survivors of CA due to congenital LQTs. A 27-year-old man was resuscitated from CA due to congenital LQTs type 3 and Brugada syndrome. Torsade de pointes (TdP) recurred spontaneously on admission (body temperature, 36.9°C). During mild hypothermia therapy, QTc increased from 499 (36.9°C) to 667 milliseconds (33.8°C), although TdP was not induced. A 13-year-old boy with congenital LQTs type 1 underwent therapeutic hypothermia after resuscitation. Short-acting β-blocker was administered intravenously during this treatment. The QTc increased from 534 (36.4°C) to 626 milliseconds (34.3°C). However, TdP did not recur during mild hypothermia therapy. In both patients, electrolyte abnormalities were checked frequently and corrected immediately. QT prolongation remained a couple of days after completion of rewarming. The withdrawal of sedative drugs and extubation were not pursued before QT shortening reached to a plateau. Both patients were fully recovered from neurologic damage. During therapeutic hypothermia, QT interval was extremely prolonged, although TdP did not recur in 2 patients with congenital LQTs. Therapeutic hypothermia may be beneficial for comatose survivors of CA due to LQTs.

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2012-05-01

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2012-05-01

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2012-05-01

American Journal of Emergency Medicine

Use of a limited lights and siren protocol in the prehospital setting vs standard usage

Factors associated with law enforcement–related use-of-force injury

Operational and financial impact of physician screening in the ED

Is urinary 5-hydroxyindoleacetic acid helpful for early diagnosis of acute appendicitis?

Ischemic-appearing electrocardiographic changes predict myocardial injury in patients with intracerebral hemorrhage

Prospective study of the elder self-neglect and ED use in a community population

Pitfalls in using serum C-reactive protein to predict bacteremia in febrile adults in the ED

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma

Incidence and predictors of ventricular arrhythmias after ST-segment elevation myocardial infarction

ED patients with vertigo: can we identify clinical factors associated with acute stroke?

Tumescent technique in digits: a subcutaneous single-injection digital block

Implications of 25% to 50% coronary stenosis with cardiac computed tomographic angiography in ED patients

The orthopedic literature 2010

The cardiac literature 2010

Another use of the ultrasound-guided transversus abdominis plane block in the ED

QT interval—what is normal? Comment on “Single-dose ziprasidone associated with QT interval prolongation”

Atropine dosage in patients with severe organophosphate pesticide poisoning

A mission statement for Emergency Medicine

Noninvasive Doppler ultrasound cardiac output monitor for the differential diagnosis of shock

Hematogenous septic arthritis of the hip in adult patients

Comment on “A novel approach to confirming nasogastric tube placement in the ED”

Posterior urethral valves diagnosed by bedside ultrasound in the ED

Unresponsive ventricular tachycardia associated with aluminum phosphide poisoning

A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage

Point-of-care ultrasound diagnosis of acute Achilles tendon rupture in the ED

Rhabdomyolysis associated with kava ingestion

Successful electrical cardioversion in a massive concentric hypertrophic cardiomyopathy with atrial fibrillation

Atraumatic neck pain and rigidity: a case of calcific retropharyngeal tendonitis

Recurrent choking as a presenting feature of aortic arch aneurysm

Concurrent pulmonary embolism and acute coronary syndrome with dynamic electrocardiographic changes

Posterior vitreal detachment in decompression illness—case report and discussion

Acute myocardial infarction in a 56-year-old female patient treated with sulfasalazine

Extreme QT prolongation during therapeutic hypothermia after cardiac arrest due to long QT syndrome

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