Point-of-Care Ultrasound to Assess Diaphragmatic Paralysis in Resource-Limited Setting: A Case Series.

Diaphragmatic dysfunction can arise from various factors, and Guillain-Barre syndrome, characterized by acute inflammatory polyradiculoneuropathy, is one such cause that may result in respiratory failure due to diaphragmatic paralysis. Prompt recognition and timely intervention, including airway protection and addressing the underlying pathology, are crucial for achieving optimal patient outcomes. Point-of-care ultrasound, specifically utilizing the M-mode function, can be employed for individuals displaying symptoms of diaphragmatic paralysis. This diagnostic approach is uncomplicated an effective tool for serial follow-up. In this context, we present a case series involving three patients with diaphragmatic paralysis in a limited-resource setting.

Monocular Painless Vision Loss in the Emergency Department: Multipurpose Utility of Point-of-Care Ultrasound.

BACKGROUND: Eye-related symptoms are a common presentation in the emergency department (ED). The cases range from simple viral conjunctivitis to trauma-related eye injuries. One pathological condition that could lead to vision loss is retinal artery occlusion (RAO). Evaluating a patient with an eye symptom requires thorough eye examination and advanced imaging in certain instances. Consultation with an ophthalmologist is also necessary for cases that require treatment recommendations and further testing. In the ED, point-of-care ultrasound (POCUS) is a commonly used diagnostic tool that can be used for ocular examination. CASE REPORT: We reported a case of a 60-year-old man who presented with painless partial right-eye vision loss. POCUS showed decreased flow in the right central retinal artery with an area of the pale retina seen on the image from the retinal camera, suggesting a possible branch RAO. Further examination with POCUS showed plaque formation at the carotid bifurcation, a potential cause of the patient's symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians and other providers should be encouraged to use POCUS to diagnose eye symptoms accurately and promptly. Abnormal findings will prompt immediate specialty consult and early appropriate management. Our case and other reported cases highlight POCUS's reliability and rapid diagnostic ability.

Role of point of care ultrasound in the absence of radial pulse and unrecordable blood pressure during the assessment of shock: Case report.

INTRODUCTION: Point-of-care ultrasound (POCUS) has been an integral part of patient evaluation in the Emergency Department. It has been used increasingly for the evaluation of critically ill and trauma patients. CASE PRESENTATION: We report a case of 60-year-old male patient who presented to the Emergency department with flank pain and urinary symptoms suggesting pyelonephritis with unrecordable blood pressure indicating potential septic shock, but the absence of bilateral radial pulses triggered the use of POCUS which reveal bilateral radial artery occlusion. CASE DISCUSSION: Assessment of the peripheral pulses (usually radial pulse) is an important clue to estimate the systolic blood pressure with presence of a pulse correlating to a systolic SBP of ≥80 mmHg. this case report showed there was an absent peripheral radial and brachial pulse despite the patient appearing hemodynamically stable and no other signs of shock. By utilizing vascular POCUS, the patient's diagnosis completely changed. The use of POCUS led to an instant diagnosis and appropriate patient management. CONCLUSION: Point-of-Care ultrasound is a valuable diagnostic tool that can help narrow down differential diagnostics and guide early proper management and intervention.

Emergency department burr hole simulation using 3D-printed model.

BACKGROUND: Traumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure. SPECIFIC AIMS: To evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases. MATERIALS AND METHODS: A 3D-printed skull, electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded. RESULTS: Twenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had overall comfort level above 5 post-simulation. CONCLUSION: The 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.

The Use of a Suprascapular Nerve Block to Facilitate the Reduction of an Anterior Shoulder Dislocation: An Alternative for Elderly and Patients With Cardiopulmonary Comorbidities?

BACKGROUND: Anterior shoulder dislocation is a common presentation to the emergency department (ED). Dislocations are spontaneous or traumatic. Generally, a reduction is performed under procedural sedation and analgesia (PSA). Other approaches include the use of intra-articular lidocaine or, in rare instances, nerve blocks. Here we discuss the case of a 66-year-old female patient who presented with left shoulder pain and limited range of motion after a fall. After discussing potential treatment options to reduce the dislocation, the patient agreed to a nerve block. DISCUSSION: The dislocation was reduced successfully with a suprascapular nerve block (SSNB) without complications. The duration of the patient's ED stay was shorter than those who had received PSA. CONCLUSIONS: SSNB could be an alternative method for shoulder dislocation reduction, particularly for patients who are obese, older, or have cardiopulmonary comorbidities.

Distal Tracheal Obstructive Mass Leading to Bilateral Pneumothorax and Respiratory Failure.

Tracheal masses are rare in occurrence, but could lead to complications depending on the speed of growth, duration and degree of obstruction. Some of the complications are recurrent pneumonia and air trapping resulting in increased intrathoracic pressure. The latter phenomenon can result in obstruction of the venous return and pneumothorax. We are reporting a rare presentation of bilateral pneumothorax (presumed tensioned) in a young patient with a distal obstructive tracheal tumor. In the emergency department (ED) the patient was in respiratory distress and was found to have extensive subcutaneous emphysema of the neck, chest, and abdominal wall with hypotension. Respiratory failure from bilateral tension pneumothorax was suspected and the patient was intubated with simultaneous bilateral thoracostomy. These measures did not improve the patient's ventilation and oxygenation status. Further fiberoptic investigation revealed a distal tracheal obstructive mass. An emergency surgical intervention was required to remove the tumor. We recommend considering alternative pathologies, such as an obstructive tracheal tumor, in a patient with respiratory distress. They should especially be considered when oxygenation and ventilation are difficult, particularly when endotracheal intubation and/or tube thoracostomy fail to improve the symptoms. A high index of suspicion and a timely multidisciplinary team approach are essential when managing the life-threatening presentation of a patient with a distal tracheal tumor.

Stakeholder Engagement In a Comparative Effectiveness/Implementation Study to Prevent Staphylococcus Aureus Infection Recurrence: CA-MRSA Project (CAMP2).

BACKGROUND: Methicillin-resistant or methicillin-sensitive Staphylococcus aureus skin and soft tissue infections pose serious clinical and public health challenges. Few protocols exist for outpatient education, decolonization and decontamination. OBJECTIVES: This trial implemented infection prevention protocols in homes via community health workers/Promotoras. METHODS: We engaged clinicians, patient stakeholders, clinical and laboratory researchers, New York-based federally qualified health centers and community hospital emergency departments. The Clinician and Patient Stakeholder Advisory Committee (CPSAC) convened in person and remotely for shared decision-making and trial oversight. RESULTS: The intervention trial consented participants with skin and soft tissue infections from Methicillin-resistant Staphylococcus aureus or methicillin-sensitive Staphylococcus aureus, completed home visits, obtained surveillance cultures from index patients and household members and sampled household environmental surfaces at baseline and three months. LESSONS LEARNED: The retention of the CPSAC during the trial demonstrated high levels of engagement. CONCLUSIONS: CPSAC was highly effective throughout design and execution by troubleshooting recruitment and home visit challenges.

Synthetic cannabinoid receptor agonists-induced recurrent seizure in elderly patient.

Abuse of synthetic cannabinoid receptor agonists (SCRAs) has been associated with young individuals. The abuse of SCRAs is very rare in elderly people, but a few cases highlight the SCRAs-induced side effects. These substances lead to a variety of clinical and psychiatric symptoms including seizures. Here we report recurrent seizures after SCRA abuse by an elderly patient.

Management and outcome of obstructive ureteral stones in the emergency department: Emphasis on urine tests and antibiotics usage.

BACKGROUND: Kidney stone related complaints in the Emergency Department (ED) are common. Current guidelines recommend antibiotic therapy for infected obstructive stones and stone removal in a timely fashion, but there is no clear recommendation for prophylactic antibiotic use for bacteriuria or pyuria in the setting of obstructive ureteral stones. OBJECTIVES: The aim of this study is to evaluate the current management of patients with obstructive ureteral stones in a single ED with emphasis on urine tests and antibiotics use. METHODS: The picture archiving and communication system (PACS) was used to filter the list of patients who received a computed tomography (CT) scan of the abdomen and pelvis that positively identified obstructive ureteral stones. Demographics and clinical data were also recorded and analyzed. RESULTS: Of the patients discharged, 278 patients did not receive antibiotics in the ED or a prescription. Of these, 8 patients had positive culture, 4 patients followed up, and one developed and was treated for a urinary-tract infection. One hundred ninety two patients were not given antibiotics in the ED but received an antibiotics prescription, and 4 patients had positive cultures grow. Two followed up and had no infection-related complications. Fourteen patients were discharged without a prescription after receiving a single dose of antibiotics in the ED, with no positive urine cultures and 9 patients following up without complication. CONCLUSION: Antibiotics were given at the discretion of the provider without clear pattern. A high rate of infectious complication did not occur in the followed up patient group.

Development and Utilization of 3D Printed Material for Thoracotomy Simulation.

Medical simulation is a widely used training modality that is particularly useful for procedures that are technically difficult or rare. The use of simulations for educational purposes has increased dramatically over the years, with most emergency medicine (EM) programs primarily using mannequin-based simulations to teach medical students and residents. As an alternative to using mannequin, we built a 3D printed models for practicing invasive procedures. Repeated simulations may help further increase comfort levels in performing an emergency department (ED) thoracotomy in particular, and perhaps this can be extrapolated to all invasive procedures. Using this model, a simulation training conducted with EM residents at an inner city teaching hospital showed improved confidence. A total of 21 residents participated in each of the three surveys [(1) initially, (2) after watching the educational video, and (3) after participating in the simulation]. Their comfort levels increased from baseline after watching the educational video (9.5%). The comfort level further improved from baseline after performing the hands on simulation (71.4%).

Effects of Novel Calpain Inhibitors in Transgenic Animal Model of Parkinson's disease/dementia with Lewy bodies.

Parkinson's disease (PD) and dementia with Lewy bodies (DLB) are neurodegenerative disorders of the aging population characterized by the accumulation of α-synuclein (α-syn). The mechanisms triggering α-syn toxicity are not completely understood, however, c-terminus truncation of α-syn by proteases such as calpain may have a role. Therefore, inhibition of calpain may be of value. The main objective of this study was to evaluate the effects of systemically administered novel low molecular weight calpain inhibitors on α-syn pathology in a transgenic mouse model. For this purpose, non-tg and α-syn tg mice received the calpain inhibitors - Gabadur, Neurodur or a vehicle, twice a day for 30 days. Immunocytochemical analysis showed a 60% reduction in α-syn deposition using Gabadur and a 40% reduction using Neurodur with a concomitant reduction in c-terminus α-syn and improvements in neurodegeneration. Western blot analysis showed a 77% decrease in α-spectrin breakdown products (SBDPs) SBDPs with Gabadur and 63% reduction using Neurodur. There was a 65% reduction in the active calpain form with Gabadur and a 45% reduction with Neurodur. Moreover, treatment with calpain inhibitors improved activity performance of the α-syn tg mice. Taken together, this study suggests that calpain inhibition might be considered in the treatment of synucleinopathies.

Prospective assessment of patients with stroke in Tikur Anbessa Specialised Hospital, Addis Ababa, Ethiopia.

INTRODUCTION: The burden of stroke is increasing in many low- and middle-income countries. In Ethiopia, stroke has become a major cause of morbidity, long-term disability, and mortality. Time from stroke onset to hospital presentation is a critical factor in acute stroke care. This study aimed to describe risk factors for stroke and clinical presentation of patients presenting to the emergency centre with stroke. METHODS: We conducted a cross sectional study conducted from August 2015 to January 2016 in an urban tertiary care centre in Addis Ababa, Ethiopia. Descriptive statistics and multivariable logistic regression models were used to evaluate associations between stroke types and stroke risk factors, and delayed presentation and clinical indicators. P-values less than .05 were considered statistically significant. RESULTS: A total of 104 patients were included. The mean age was 53 years, and 56% were male. Only 30% of patients arrived using an ambulance service. The most common presenting symptoms were altered mental status (48%), hemiparesis (47%), facial palsy (45%), hemiplegia (29%), and aphasia (25%). Hypertension was the most common risk factor (49%), followed by cardiovascular disease (20.2%) and diabetes mellitus (11%). The majority of strokes were haemorrhagic in aetiology (56%). The median arrival time to the emergency centre was 24 h after symptoms onset; only 15% presented within three hours. Patients with hypertension, or presented with loss of consciousness were significantly more likely to have haemorrhagic stroke (p < .001 and p = .01 respectively). The only risk factor robustly associated with ischaemic stroke was cardiac illness (odds ratio 3.99, p = .01). DISCUSSION: Our study identified hypertension to be the most common risk factor for stroke. The predominant aetiology type in this cohort is haemorrhagic stroke. Lastly, the median arrival time to an emergency centre was 24 h after symptom onset.

The Role of Acetyl Cysteine in Cocaethylene (Non-Acetaminophen) Acute Liver Failure.

BACKGROUND: Acute liver failure can result from acetaminophen overdose, viral infection, toxins, and other disease conditions. Liver transplant is available in limited fashion and the criteria are strict as to who should get an available liver. N- Acetyl Cysteine (NAC) has been used in non-acetaminophen induced liver failure with success. Here we report a case of acute liver failure from cocaethylene that was reversed with NAC along with other medical therapy. CASE PRESENTATION: A 50-year-old female patient presented to the Emergency Department (ED) with a two-day history of coffee ground vomiting and hematemesis. She reported occasional substance abuse and heavy alcoholism. She reported shortness of breath and chest pain from the recurrent forceful vomiting. The rest of the review of systems was unremarkable except a fall from intoxication. Physical examination revealed anicteric conjunctiva and nontender abdomen and her vital signs were within normal limits. Initial blood work revealed acute liver and renal failure. The patient was started with general medical management and liver transplant service rejected the case due to active substance abuse. She underwent brief hemodialysis and was started on NAC. Over the course of her hospital stay her liver function and kidney function improved significantly and patient was discharged to home. CONCLUSION: In cases where liver transplant is not an option for various reasons including active substance abuse, a trial of N-Acetyl Cysteine may be beneficial and should be considered in the Emergency Department.

Controlled cortical impact-induced neurodegeneration decreases after administration of the novel calpain-inhibitor Gabadur.

One aspect of secondary injury in traumatic brain injury is the marked increase in intracellular calcium and resultant over-activation of the calcium-dependent neutral cysteine protease calpain. Gabadur is a novel protease inhibitor with calpain-inhibition properties formulated from the classic protease inhibitor leupeptin linked to a pregabalin carrier. This construction allows the entire compound to cross the blood-brain barrier after peripheral administration to better target the site of injury. In this study, a single intraperitoneal dose of Gabadur was administered immediately following controlled cortical impact injury in rats. Neocortical slices were examined at 48 h post-injury via Fluoro-Jade B staining, revealing an improvement in cortical neurodegeneration in Gabadur treated rats. Levels of detrimental active calpain-2 measured via western blot were also decreased in rats receiving Gabadur. This data supports the benefit of targeted protease inhibition in the treatment of traumatic brain injury.

Acute stent thrombosis: Should preventative measures start in the emergency department?

Stent thrombosis is a potentially life threatening condition caused by several factors or a combination factors, such as resistance to platelet agents and type of anticoagulation used as well as stent types. We report a case of acute thrombosis and discuss potential areas of intervention with literature review.

Real time optic nerve sheath diameter measurement during lumbar puncture.

Measurement of optic nerve sheath diameter (ONSD) using point of care ultrasound has been used to indirectly assess the intracranial pressure (ICP) particularly in conditions where it is raised. Direct pressure measurements using probes reaching the ventricle system correlated with ONSD using ultrasound. Attempts were made to measure the ONSD pre and post lumbar puncture (LP) after draining cerebrospinal fluid (CSF) as well as post ventricular shunt placement. We report ONSD measurement and demonstrate dynamic changes during LP in a patient with known idiopathic intracranial hypertension (IIH).

Is topical tranexamic acid a better alternative for selected cases of anterior epistaxis management in the ED?

Epistaxis is a well-known problem that is mostly self-limited. In certain cases it requires packing or cauterization. Tranexamic acid has been tried and has shown promising results. Here we report a case of prolonged epistaxis in a patient on dual anti-platelet agent therapy.