Spontaneous epiglottic hematoma secondary to direct oral anticoagulant.

Spontaneous hemorrhage is a known risk for patients on anticoagulation therapy. Most previous spontaneous airway hemorrhage cases reported involve warfarin, and of the few that involved a direct oral anticoagulant, none involved the epiglottis. The following case describes a spontaneous epiglottic hematoma in a patient one week after starting a direct oral anticoagulant. An 85-year-old man presented to the emergency department with acute onset of neck swelling, odynophagia and sublingual ecchymosis. Evaluation in the emergency department included advanced imaging of the neck and consultation with otolaryngology. Flexible fiberoptic laryngoscopy showed a markedly enlarged and ecchymotic epiglottis. The patient received medical management including rivaroxaban reversal, steroids, and broad-spectrum antibiotics, but no airway management was deemed necessary. After close monitoring, the patient was discharged on hospital day two. Further research and risk profiling could benefit patients and emergency clinicians when considering spontaneous hemorrhage in the airway in patients taking a direct oral anticoagulant.

SARS-CoV-2 Seroprevalence and Drug Use in Trauma Patients from Six Sites in the United States.

In comparison to the general patient population, trauma patients show higher level detections of bloodborne infectious diseases, such as Hepatitis and Human Immunodeficiency Virus. In comparison to bloodborne pathogens, the prevalence of respiratory infections such as SARS-CoV-2 and how that relates with other variables, such as drug usage and trauma type, is currently unknown in trauma populations. Here, we evaluated SARS-CoV-2 seropositivity and antibody isotype profile in 2,542 trauma patients from six Level-1 trauma centers between April and October of 2020 during the first wave of the COVID-19 pandemic. We found that the seroprevalence in trauma victims 18-44 years old (9.79%, 95% confidence interval/CI: 8.33 - 11.47) was much higher in comparison to older patients (45-69 years old: 6.03%, 4.59-5.88; 70+ years old: 4.33%, 2.54 - 7.20). Black/African American (9.54%, 7.77 - 11.65) and Hispanic/Latino patients (14.95%, 11.80 - 18.75) also had higher seroprevalence in comparison, respectively, to White (5.72%, 4.62 - 7.05) and Non-Latino patients (6.55%, 5.57 - 7.69). More than half (55.54%) of those tested for drug toxicology had at least one drug present in their system. Those that tested positive for narcotics or sedatives had a significant negative correlation with seropositivity, while those on anti-depressants trended positive. These findings represent an important consideration for both the patients and first responders that treat trauma patients facing potential risk of respiratory infectious diseases like SARS-CoV-2.

Concurrent Proximal Fractures Are Rare in Distal Forearm Fractures: A National Cross-sectional Study.

INTRODUCTION: Distal forearm fractures (DFF) account for 1.5% of emergency department (ED) visits in the United States. Clinicians frequently obtain imaging above/below the location of injury to rule out additional injuries. We sought to determine the incidence of associated proximal fractures (APF) in the setting of DFF and to evaluate the imaging practices in a nationally representative sample of EDs. METHODS: We queried the 2013 National Emergency Department Sample using International Classification of Diseases, 9th edition, diagnostic codes for DFF and APF. Current Procedural Technology codes identified associated imaging studies. We calculated national estimates using a weighted analysis of patient and hospital-level characteristics associated with APF and imaging practices. An analysis of costs estimated the financial impact of additional imaging in patients with DFF using Medicare reimbursement to approximate costs according to the 2018 Medicare Physician Fee Schedule. RESULTS: In 2013, an estimated 297,755 ED visits (weighted) were associated with a DFF, of which 1.6% (4836 cases) had an APF. The incidence of APF was lower among females (odds ratio [OR] (0.76); 95% confidence interval [CI], 0.64-0.91) but higher in metropolitan teaching hospitals compared to metropolitan non-teaching hospitals (OR [2.39]; 95% CI, 1.43-3.99) and Level 1 trauma centers (OR [3.9]; 95%, 1.91-7.96) compared to non-trauma centers. Approximately 40% (n = 117,948) of those with only DFF received non-wrist radiographs and 19% (n = 55,236) underwent non-wrist/non-forearm imaging. Factors independently associated with additional imaging included gender, payer, patient and hospital rurality, hospital region, teaching status, ownership, and trauma center level. Nearly $3.6 million (2018 U.S. dollars) was spent on the aforementioned additional imaging. CONCLUSION: Despite the frequency of proximal imaging in patients with DFF, the incidence of APF was low. Further study to identify risk factors for APF based on mechanism and physical examination factors may result in reduced imaging and decreased avoidable healthcare spending.

Emergency Medicine Residency Selection Criteria: An Update and Comparison.

OBJECTIVE: The primary objective was to describe emergency medicine (EM) residency selection criteria. METHODS: A survey was sent to the Council of Emergency Medicine Residency Directors listserv. Respondents were asked to rank order the various components of the application on a Likert scale from 1 (minimally important) to 10 (highly important). The mean ranking and standard deviation for each of the components were calculated. The survey sought to determine characteristics associated with offering an applicant an invitation to interview and subsequent ranking. Percentages with defined minimum requirements were calculated. Comparisons across residency length and location were completed with a Pearson chi-square test for categorical variables and Student's t-test for continuous variables. RESULTS: A total of 120 surveys were completed. The highest ranked components included away/visiting institution departmental standardized letter of evaluation (SLOE) (mean ± SD = 8.80 ± 1.25), residency interview (mean ± SD = 8.74 ± 1.28), home institution departmental SLOE (mean ± SD = 8.61 ± 1.18), away/visiting institution EM rotation grade (mean ± SD = 8.29 ± 1.43), and home institution EM rotation grade (mean ± SD = 8.07 ± 1.42). The most consistently ranked items included home institution departmental SLOE (SD = 1.18), away/visiting institution departmental SLOE (1.25), and residency interview (1.28). Characteristics associated with offering an interview to an applicant included only 10% of responses indicating a United States Medical Licensing Examination Step 1 score of 220 was needed. At least one SLOE was required in 80% of responses. Program location was related to the number of SLOEs required (p = 0.03). Length of residency and program location differed significantly in how a residency ranked components when considering an applicant (p < 0.05). CONCLUSION: Emergency medicine programs put high value in departmental SLOEs, the interview, and EM rotation grades when selecting potential residents. Higher value is placed on SLOEs and grades from away/visiting institutions compared with students' home institutions.

An evidence-based medicine curriculum implemented in journal club improves resident performance on the Fresno test.

BACKGROUND: Journal club is a standard component of residency education. Journal club focuses on review and interpretation of the medical literature with varying degrees of evidence-based medicine (EBM) education. OBJECTIVES: To evaluate learning of EBM principles with an EBM curriculum implemented as a component of journal club. EBM competency was established using the Fresno test, a validated 12-question instrument of short-answer and essay-style questions to assess competency in EBM. METHODS: An EBM curriculum was implemented that consisted of a focus on EBM topics (e.g., study validity, bias, confidence intervals, search strategies) using a structured journal club format using a peer instruction model. The Fresno test was used prior to and after the implementation of the first year of this curriculum to measure effectiveness of the intervention. A hierarchical multivariable model using generalized estimating equations was used to account for repeated measures in the primary outcome of change in total Fresno test score. RESULTS: The total test scores did not increase significantly (105.4 vs. 120.9, p = 0.058) in the before-after analysis. The only subscore showing improvement was interpretation of study validity (32.1 vs. 40.4 points, p = 0.03). Attendance was significantly associated with Fresno test score, with those attending ≥ 6/11 sessions (55%) scoring 28.2 points higher (p = 0.003), and those attending fewer than six sessions scoring only 1.9 points higher (p = 0.81) than in the preintervention group. CONCLUSION: An EBM curriculum implemented as part of journal club improves performance on the Fresno test among residents who attended at least six journal club sessions.

Torsion of an undescended testis located in the inguinal canal.

BACKGROUND: Torsion of undescended testis located within the inguinal canal is a rare finding in the emergency department (ED). This diagnosis can present as undifferentiated abdominal or groin pain, and a full genitourinary examination is essential to making this diagnosis. OBJECTIVES: We present this case to increase awareness among emergency physicians regarding torsion of undescended testis. CASE REPORT: A 5-year-old boy presented to the ED with abdominal pain and a mass in his right groin. Physical examination and Doppler ultrasound were used to diagnose torsion of undescended testis. CONCLUSIONS: In a patient with undescended testis, torsion must be considered as a cause of abdominal or groin pain. Full genitourinary examination is essential to making this diagnosis.

Treating primary headaches in the ED: can droperidol regain its role?

OBJECTIVE: The aim of this study was to describe the use and efficacy of low-dose (≤2 mg) droperidol for the treatment of primary headaches (ie, migraine, cluster, tension-type headache and trigeminal autonomic cephalalgias, and other primary headaches) in the emergency department (ED). METHODS: A report was generated from a pharmacy database to identify all adult patients who received low-dose droperidol in the ED over a 7-month period; a subsequent retrospective chart review was conducted. Low-dose droperidol was defined as a cumulative dose of ≤2 mg. Patients who received droperidol for any other reason than the treatment of a headache were excluded. Data were analyzed descriptively. RESULTS: Seventy-three cases in which droperidol was administered for the treatment of a headache were identified over the 7-month period. Most doses (92%) administered were 1.25 mg or less. Fifty-three patients (73%) had complete resolution or significant improvement of headache symptoms as subjectively or objectively (eg, numerical pain scale) documented by the treating physician. Eight patients (11%) had minimal improvement in their headaches symptoms; 12 patients (16%) received no relief after the administration of droperidol. The average time to discharge from the ED was 94.8 ± 67.2 minutes. No cardiac arrhythmias were noted. Other adverse events included 2 cases of extrapyramidal side effects; one patient reported restlessness/anxiousness and the other patient had dystonia. CONCLUSION: The administration of low-dose (≤2 mg) droperidol may be safe and effective for the treatment of primary headaches in the ED.

Comparison of postsimulation debriefing versus in-simulation debriefing in medical simulation.

INTRODUCTION: A key portion of medical simulation is self-reflection and instruction during a debriefing session; however, there have been surprisingly few direct comparisons of various approaches. The objective of this study was to compare two styles of managing a simulation session: postsimulation debriefing versus in-simulation debriefing. METHODS: One hundred sixty-one students were randomly assigned to receive either postsimulation debriefing or in-simulation debriefing. Retrospective pre-post assessment was made through survey using Likert-scale questions assessing students' self-reported confidence and knowledge level as it relates to medical resuscitation and statements related to the simulation itself. RESULTS: There were statistically significant differences in the reliable self-reported results between the two groups for effectiveness of the debriefing style, debriefing leading to effective learning, and the debriefing helping them to understand the correct and incorrect actions, with the group that received postsimulation debriefing ranking all these measures higher. Both groups showed significantly higher posttest scores compared with their pretest scores for individual and overall measures. DISCUSSION: Students felt that a simulation experience followed by a debriefing session helped them learn more effectively, better understand the correct and incorrect actions, and was overall more effective compared with debriefing that occurred in-simulation. Students did not feel that interruptions during a simulation significantly altered the realism of the simulation.

Gene delivery of l-caldesmon protects cytoskeletal cell membrane integrity against adenovirus infection independently of myosin ATPase and actin assembly.

The cytoskeleton is critical to the viral life cycle. Agents like cytochalasin inhibit viral infections but cannot be used for antiviral therapy because of their toxicity. We report the efficacy, safety, and mechanisms by which gene delivery of human wild-type low-molecular-weight caldesmon (l-CaD) protects cell membrane integrity from adenovirus infection in a DF-1 cell line, an immortalized avian fibroblast that is null for l-CaD. Transfection with an adenovirus (Ad)-controlled construct mediated a dose-dependent decline in transcellular resistance. In accordance with a computational model of cytoskeletal membrane properties, Ad disturbed cell-cell and cell-matrix adhesion and membrane capacitance. Transfection with the Ad-l-CaD construct attenuated adenovirus-mediated loss in transcellular resistance. Quantitation of vinculin-stained plaques revealed an increase in total focal contact mass in monolayers transfected with the Ad-l-CaD construct. Expression of l-CaD protected transcellular resistance through primary effects on membrane capacitance and independently of actin solubility and effects on pre-stress, as measured by the decline in isometric tension in response to cytochalasin D. Expression of l-CaD exhibited less Trypan blue cell toxicity than cytochalasin, and, unlike cytochalasin, it did not interfere with wound closure or adversely effect transcellular resistance. These findings demonstrate the gene delivery of wild-type human l-CaD as a potentially efficacious and safe agent that inhibits some of the cytopathic effects of adenovirus.