Rhino-Orbital Cerebral Mucormycosis in a Diabetic Patient: An Emergency Medicine Case Report.

BACKGROUND: Rhino-orbital cerebral mucormycosis (ROCM) is a rare infection caused by an invasive fungus and found predominantly in immunocompromised patients. The presentation of ROCM ranges from a mild headache, fever, and sinusitis to vision loss, altered mental status, and facial disfigurement secondary to local tissue invasion. ROCM can cause significant morbidity and mortality and requires prompt diagnosis with timely evaluation by surgical and infectious disease specialists. Cases of ROCM have been reported extensively in internal medicine, infectious disease, and otolaryngology literature. However, there are very few reports in emergency medicine literature in the United States. CASE REPORT: A 72-year-old woman presented to the Emergency Department (ED) with altered mental status, 4 days of left-sided facial numbness and weakness, and sudden facial pain, swelling, and erythema. Laboratory analysis was consistent with diabetic ketoacidosis. Noncontrast computed tomography of the head and magnetic resonance imaging of the brain demonstrated findings indicative of invasive fungal infection of the left sinus and orbit with extension to the cavernous sinus and surrounding cranial nerves. She was initiated on broad-spectrum antifungals, but based on the extent of the infection, was not a surgical candidate. She subsequently transitioned to a comfort-based plan of care and died 6 days after initial ED presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early recognition and initiation of treatment can potentially mitigate the devastating outcomes of ROCM, therefore it is critical to be aware of this condition and have a high level of suspicion in susceptible patients.

Implementation of the SIMPL (Society for Improving Medical Professional Learning) performance assessment tool in the emergency department: A pilot study.

Background: Feedback and assessment are difficult to provide in the emergency department (ED) setting despite their critical importance for competency-based education, and traditional end-of-shift evaluations (ESEs) alone may be inadequate. The SIMPL (Society for Improving Medical Professional Learning) mobile application has been successfully implemented and studied in the operative setting for surgical training programs as a point-of-care tool that incorporates three assessment scales in addition to dictated feedback. SIMPL may represent a viable tool for enhancing workplace-based feedback and assessment in emergency medicine (EM). Methods: We implemented SIMPL at a 4-year EM residency program during a pilot study from March to June 2021 for observable activities such as medical resuscitations and related procedures. Faculty and residents underwent formal rater training prior to launch and were asked to complete surveys regarding the SIMPL app's content, usability, and future directions at the end of the pilot. Results: A total of 36/58 (62%) of faculty completed at least one evaluation, for a total of 190 evaluations and an average of three evaluations per faculty. Faculty initiated 130/190 (68%) and residents initiated 60/190 (32%) evaluations. Ninety-one percent included dictated feedback. A total of 45/54 (83%) residents received at least one evaluation, with an average of 3.5 evaluations per resident. Residents generally agreed that SIMPL increased the quality of feedback received and that they valued dictated feedback. Residents generally did not value the numerical feedback provided from SIMPL. Relative to the residents, faculty overall responded more positively toward SIMPL. The pilot generated several suggestions to inform the optimization of the next version of SIMPL for EM training programs. Conclusions: The SIMPL app, originally developed for use in surgical training programs, can be implemented for use in EM residency programs, has positive support from faculty, and may provide important adjunct information beyond current ESEs.

Initiation of a Lung Protective Ventilation Strategy in the Emergency Department: Does an Emergency Department-Based ICU Make a Difference?

BACKGROUND: Lung protective ventilation (LPV) is a key component in the management of acute respiratory distress syndrome and other acute respiratory pathology. Initiation of LPV in the emergency department (ED) is associated with improved patient-centered and system outcomes, but adherence to LPV among ED patients is low. The impact of an ED-based ICU (ED-ICU) on LPV adherence is not known. METHODS: This single-center, retrospective, cohort study analyzed rates of adherence to a multifaceted LPV strategy pre- and post-implementation of an ED-ICU. LPV strategy components included low tidal volume ventilation, avoidance of severe hyperoxia and high plateau pressures, and positive end-expiratory pressure settings in alignment with best-evidence recommendations. The primary outcome was adherence to the LPV strategy at time of ED departure. RESULTS AND CONCLUSIONS: A total of 561 ED visits were included in the analysis, of which 60.0% received some portion of their emergency care in the ED-ICU. Adherence to the LPV strategy was statistically significantly higher in the ED-ICU cohort compared with the pre-ED-ICU cohort (65.8% vs 41.4%; p < 0.001) and non-ED-ICU cohort (65.8% vs 43.1%; p < 0.001). Among the ED-ICU cohort, 92.8% of patients received low tidal volume ventilation. Care in the ED-ICU was also associated with shorter ICU and hospital length of stay. These findings suggest improved patient and resource utilization outcomes for mechanically ventilated ED patients receiving care in an ED-ICU.

Impact of Providing a Tape Measure on the Provision of Lung-protective Ventilation.

INTRODUCTION: Emergency department (ED) patients are frequently ventilated with excessively large tidal volumes for predicted body weight based on height, which has been linked to poorer patient outcomes. We hypothesized that supplying tape measures to respiratory therapists (RT) would improve measurement of actual patient height and adherence to a lung-protective ventilation strategy in an ED-intensive care unit (ICU) environment. METHODS: On January 14, 2019, as part of a ventilator-associated pneumonia prevention bundle in our ED-based ICU, we began providing RTs with tape measures and created a best practice advisory reminding them to record patient height. We then retrospectively collected data on patient height and tidal volumes before and after the intervention. RESULTS: We evaluated 51,404 tidal volume measurements in 1,826 patients over the 4 year study period; of these patients, 1,579 (86.5%) were pre-intervention and 247 (13.5%) were post-intervention. The intervention was associated with a odds of the patient's height being measured were 10 times higher post-intervention (25.1% vs 3.2%, P <0.05). After the bundle was initiated, we observed a significantly higher percentage of patients ventilated with mean tidal volumes less than 8 cubic centimeters per kilogram (93.9% vs 84.5% P < 0.05). CONCLUSION: Patients in an ED-ICU environment were ventilated with a lung-protective strategy more frequently after an intervention reminding RTs to measure actual patient height and providing a tape measure to do so. A significantly higher percentage of patients had height measured rather than estimated after the intervention, allowing for more accurate determination of ideal body weight and calculation of lung-protective ventilation volumes. Measuring all mechanically ventilated patients' height with a tape measure is an example of a simple, low-cost, scalable intervention in line with guidelines developed to improve the quality of care delivered to critically ill ED patients.

Euglycemic diabetic ketoacidosis associated with SGLT2i use: Case series.

INTRODUCTION: Euglycemic diabetic ketoacidosis (EuDKA) associated with Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use has been described but remains poorly understood. Data on Emergency Department (ED) presentation, resource utilization, and safety outcomes for these patients are lacking. We report a case series of patients diagnosed with EuDKA in the ED. METHODS: An electronic medical record search identified adult patients presenting to a large tertiary ED with EuDKA. They were screened for concurrent use of SGLT2i. Clinical presentation, resource utilization, safety, and disposition data were collected and described. RESULTS: Five patients were included for analysis. Median age [range] was 57 [43-73] years. Presenting symptoms included nausea, vomiting, fatigue, and altered mental status. Initial results included: serum glucose 191 mg/dL [176-215], venous pH 7.01 [6.95-7.30], serum HCO3 8 mEq/L [6-13], anion gap 27 [26-31], serum beta-hydroxybutyrate 9.9 mmol/L [9.2-12.3], and urine ketones 150 [150-150]. Patients remained on an insulin infusion for 18.77 h [11.25-56.48]. There were zero episodes of hypoglycemia and one episode of hypokalemia while on insulin infusion. Time to resolution of metabolic acidosis was 23.82 h [15.45-24.77]. DISCUSSION: We report a case series of ED patients with EuDKA associated with SGLT2i use, and describe presentation characteristics, resource utilization, and safety outcomes. Emergency physicians should be aware of the association between SGLT2i use and EuDKA. An appropriate work-up should be pursued for patients taking an SGLT2i who present with symptoms suggestive of DKA, including nausea, vomiting, malaise, and altered mental status, or are noted to have an unexplained elevated anion gap metabolic acidosis.

Delivery of end-of-life care in an emergency department-based intensive care unit.

OBJECTIVE: Intensive care unit (ICU) admissions near the end of life have been associated with worse quality of life and burdensome costs. Patients may not benefit from ICU admission if appropriate end-of-life care can be delivered elsewhere. The objective of this study was to descriptively analyze patients receiving end-of-life care in an emergency department (ED)-based ICU (ED-ICU). METHODS: This is a retrospective analysis of patient outcomes and resource use in adult patients receiving end-of-life care in an ED-ICU. In 2015, an "End of Life" order set was created to standardize delivery of palliative therapies and comfort measures. We identified adult patients (>18 years) receiving end-of-life care in the ED-ICU from December 2015 to March 2020 whose clinicians used the end-of-life order set. RESULTS: A total of 218 patients were included for analysis; 50.5% were female, and the median age was 73.6 years. The median ED-ICU length of stay was 13.3 hours (interquartile range, 7.4-20.6). Two patients (0.9%) were admitted to an inpatient ICU, 117 (53.7%) died in the ED-ICU, 77 (35.3%) were admitted to a non-intensive care inpatient service, and 22 (10.1%) were discharged from the ED-ICU. CONCLUSIONS: An ED-ICU can be used for ED patients near the end of life. Only 0.9% were subsequently admitted to an ICU, and 10.1% were discharged from the ED-ICU. This practice may benefit patients and families by avoiding costly ICU admissions and benefit health systems by reducing ICU capacity strain.

The ED-SED Study: A Multicenter, Prospective Cohort Study of Practice Patterns and Clinical Outcomes Associated With Emergency Department SEDation for Mechanically Ventilated Patients.

OBJECTIVES: To characterize emergency department sedation practices in mechanically ventilated patients, and test the hypothesis that deep sedation in the emergency department is associated with worse outcomes. DESIGN: Multicenter, prospective cohort study. SETTING: The emergency department and ICUs of 15 medical centers. PATIENTS: Mechanically ventilated adult emergency department patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All data involving sedation (medications, monitoring) were recorded. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5 or Sedation-Agitation Scale of 2 or 1. A total of 324 patients were studied. Emergency department deep sedation was observed in 171 patients (52.8%), and was associated with a higher frequency of deep sedation in the ICU on day 1 (53.8% vs 20.3%; p < 0.001) and day 2 (33.3% vs 16.9%; p = 0.001), when compared to light sedation. Mean (SD) ventilator-free days were 18.1 (10.8) in the emergency department deep sedation group compared to 20.0 (9.8) in the light sedation group (mean difference, 1.9; 95% CI, -0.40 to 4.13). Similar results according to emergency department sedation depth existed for ICU-free days (mean difference, 1.6; 95% CI, -0.54 to 3.83) and hospital-free days (mean difference, 2.3; 95% CI, 0.26-4.32). Mortality was 21.1% in the deep sedation group and 17.0% in the light sedation group (between-group difference, 4.1%; odds ratio, 1.30; 0.74-2.28). The occurrence rate of acute brain dysfunction (delirium and coma) was 68.4% in the deep sedation group and 55.6% in the light sedation group (between-group difference, 12.8%; odds ratio, 1.73; 1.10-2.73). CONCLUSIONS: Early deep sedation in the emergency department is common, carries over into the ICU, and may be associated with worse outcomes. Sedation practice in the emergency department and its association with clinical outcomes is in need of further investigation.