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.

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.

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.

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.

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).

A tick-acquired red meat allergy.

Allergic reaction is a common clinical picture in the Emergency Department (ED). Most allergic reactions are from food or drugs. A detailed history is an integral aspect of determining the causative agent of an allergy. Galactose-alpha-1,3-galactose (alpha-gal) allergy is a tick-acquired red meat allergy that causes delayed-onset allergic reaction or anaphylaxis due to molecular mimicry. Alpha-gal allergy may not be widely known as a cause of allergic reactions. Lack of universal awareness of this phenomenon in the ED and Urgent Care setting could lead to misdiagnosis, or delayed diagnosis. Subsequently, lack of proper instruction to avoid red meat could put patients at risk for future attacks with morbidity or mortality. We report three cases of allergic reaction presumed from red meat consumption secondary to alpha-gal allergy.

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.

When a seizure is not a real seizure!

We report here 2 cases of methadone induced Torsades de Pointes with a clinical presentation mimicking convulsive seizures in a substance abuser. These cases highlight the importance of being aware of methadone-induced Torsades de Pointes and the occasional atypical clinical presentations of this condition.

Hyperthermia and severe rhabdomyolysis from synthetic cannabinoids.

Synthetic cannabinoids (SC) have exploded on to the scene. With this rise in SC use, the number of complications and potential adverse effects are also well documented in the literature and is on the rise. The most frequently cited side effects are behavioral in nature and range for severe agitation to psychosis and delirium. We report a case of hyperthermia with severe rhabdomyolysis from SC use.

Looking at diabetic ketoacidosis through electrocardiogram window!

BACKGROUND: Initial serum potassium (K+) in diabetic ketoacidosis (DKA) often does not reflect the true amount of total body K+ storage, and it is not a good predictor of subsequent hypokalemia. In this study, we tested the hypothesis that a deficiency of the total body K+ storage can be detected initially on surface electrocardiography (ECG). METHOD: Medical records of 350 patients with a diagnosis of DKA were reviewed. Data regarding serial basic metabolic panels, arterial blood gases, serum ketones, and total K+ replacement that patient received during admission were collected. We compared biochemical findings for patients with and without QTU corrected (QTUc) prolongation by using the t test. Patients who were taking medications known to affect QTUc or cause ST-T changes were excluded. RESULTS: After exclusion criteria, 61 patients were enrolled in this study. In 38 patients (62.9%), QTUc was more than or equal to 450 milliseconds. Patients with prolonged QTc received statistically more K+ supplementation during admission (P = .014). They also had lower serum K+ level during their hospital course (P = .002) compared to patients with normal QTUc intervals. No significant difference was found between initial serum K+, calcium, glucose, anion gap, acidosis, age, or heart rate between these 2 groups. CONCLUSION: The significant relationship between K+ depletion and the ECG changes observed in this study deserves further consideration. Our findings confirm the concept that the ECG is an easy and reliable tool for early diagnosis of hypokalemia in patients with DKA.

Synthetic Cannabinoids and Their Effects on the Cardiovascular System.

BACKGROUND: In the past couple of years, there has been an outbreak of synthetic cannabinoid (SC) use in major cities in the United States. Patients can present with various symptoms affecting the central nervous and cardiovascular systems. The effects of endocannabinoid on contractility and Ca(2+) signaling have been shown through both cannabinoid receptors and a direct effect on ion channels. These effects result in abnormalities in ionotropy, chronotropy, and conduction. CASE REPORT: Here we report on two cases of SC abuse and abnormalities in the cardiovascular system. These cases raise concerns about the adverse effects of SCs and the possibility of QTc prolongation and subsequent complications when using antipsychotic medication in the presence of SC abuse. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the rise in SC use and the potential effect on the cardiovascular system, physicians need to be mindful of potential cardiac complications, such as QTc prolongation and torsade de pointe, especially when administering medications that have the potential to cause QTc prolongation.

Anterior chamber depth measurement using ultrasound to assess elevated intraocular pressure.

Increased anterior chamber pressure also known as intraocular pressure can result from conditions such as glaucoma and trauma. The pressure in the anterior chamber is measured using tonometer. Measurement of the intraocular pressure is essential, as it requires immediate medical attention to alleviate pain and to avoid temporary or permanent damage to intraocular structures. Bedside ocular ultrasound (US) has gained popularity in recent years. It has been used to assess intracranial pressure via optic nerve sheath diameter (ONSD) and evaluate retinal detachment, vitreous hemorrhage, or pupillary reflex in a trauma patient. We report 2 cases of patients with glaucoma and a case of a patient with trauma to the eye with swelling. Anterior chamber depth measurement was conducted and compared with measurements of intraocular pressure (IOP) using a tonometer.

Hazards with ordering troponin in patients with low pretest probability of acute coronary syndrome.

BACKGROUND: In clinical practice, we progressively rely on biomarkers, without estimating the pretest probability. There is not enough support for the use of cardiac troponin (cTn) I in the management of noncardiac patients. We studied the rate at which this test was ordered, the prevalence of detection of a positive result in noncardiac patients, and the impact of this incidental finding on clinical management. METHODOLOGY: Patients admitted from December 2011 to 2013 to our community hospital with diagnosis of noncardiac disease who had positive cTn were included. Data collected included final diagnosis, patient disposition, cardiac monitoring, cardiology consult, and cardiac biomarker testing. RESULTS: Cardiac troponin I was ordered for 1700 patients in our emergency department. Seven hundred fifty patients had a positive cTn. Of the 750 patients, 412 had a positive cTn without any clinical suspicion of an acute coronary syndrome. An incidental finding of a positive cTn leads to ordering of cTn on average 4 times during admission, cardiac monitoring of 379 (91.99%) patients for at least 1 day, and a cardiac consultation for 268 (63.65%) of these patients. None of these patients was candidates for an invasive cardiac intervention. Seventy-eight (19.17%) patients were admitted to the cardiac care unit and subsequently transferred to the medical intensive care unit. CONCLUSIONS: A positive cTn in patients diagnosed with a nonacute coronary syndrome was associated with increased cardiac biomarker testing, telemetry monitoring, and cardiology consults. This study supports adherence to national guidelines for the use of cTn, to reduce hospital cost and resource utilization.

Accuracy of optic nerve sheath diameter measurement by emergency physicians using bedside ultrasound.

BACKGROUND: Ultrasound (US) measurement of the optic nerve sheath diameter (ONSD) has been utilized as an indirect assessment of intracranial pressure. It is usually performed by trained ultrasonographers. OBJECTIVES: To evaluate whether or not emergency physicians (EP) are capable of measuring the ONSD accurately by US. MATERIALS AND METHODS: A retrospective measurement of ONSD was conducted on computed tomography (CT) scans of the head or facial bones. These patients had undergone ocular US performed by EPs prior to CT scanning. The CT scan measurements of ONSD read by a board-certified radiologist were compared with that of the US read by a registered diagnostic medical sonographer. A difference in measurements of the ONSD ≥ 0.5 mm between the two modalities was considered as significant for this study. RESULTS: The ONSD measurements were performed with CT scan and compared to that of the US. Of the 61 patients studied, 36 (59%) were male and 25 (41%) were female. The average age was 56 ± 17 years. All but 4 patients had ONSD measurements that were between 5 and 6 mm [Corrected]. Discrepancy in measurements of the ONSD between US and CT for both groups fell within our predetermined value (0.5 mm) for the majority of cases. None of the measurements were above 6 mm. The intraclass correlation coefficient was 0.9 (95% confidence interval 0.8846-0.9303). CONCLUSION: Emergency physicians were capable of accurately measuring the ONSD using bedside US. Prospective studies with a larger sample size are recommended to validate these findings.

Lead aVL on electrocardiogram: emerging as important lead in early diagnosis of myocardial infarction?

Although a diagnosis of acute myocardial infarction (AMI) that mandates emergency reperfusion therapy requires ST-segment elevation greater than 1 mm in at least 2 contiguous leads, some of the early electrocardiogram (ECG) changes of AMI can be subtle. Any ST-segment depression or T-wave inversion in lead aVL may be implicated in left anterior descending artery lesion or early reciprocal changes of inferior wall myocardial infarction, particularly when the clinical context suggests ischemia. Early recognition of reciprocal changes and serial ECG help initiate early appropriate intervention. Heightened awareness of ST segment and T-wave changes in lead aVL is of paramount importance to quickly identifying life-threatening condition.

The role of bedside ultrasound in pretherapeutic and posttherapeutic lumbar puncture in patient with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is often a debilitating condition characterized by headaches, blurry vision, nausea, and vomiting. Lumbar puncture (LP) is an essential component of the diagnostic and therapeutic approach; however, the procedure itself can cause postlumbar puncture headache. In addition to the clinical presentation, the use of bedside ultrasound to measure the optic nerve sheath diameter may aid in differentiating the 2 conditions.We hereby report a case of a 33-year old woman with known IIH who presented with recurrent headache after the initial therapeutic LP.

The neglected lead on electrocardiogram: T wave inversion in lead aVL, nonspecific finding or a sign for left anterior descending artery lesion?

BACKGROUND: The electrocardiogram (ECG) is the most important diagnostic tool for acute myocardial infarction (AMI). T wave inversion (TWI) in lead aVL has not been emphasized or well recognized. OBJECTIVE: This study examined the relationship between the presence of TWI before the event and mid-segment left anterior descending (MLAD) artery lesion in patients with AMI. METHODS: Retrospective charts of patients with acute coronary syndrome between the months of January 2009 and December 2011 were reviewed. All patients with MLAD lesion were identified and their ECG reviewed for TWI in lead aVL. RESULTS: Coronary angiography was done on 431 patients. Of these, 125 (29%) had an MLAD lesion. One hundred and six patients (84.8%) had a lesion > 50% and 19 patients (15.2%) had a lesion < 50%. Of the 106 patients who had a MLAD lesion > 50%, 90 patients (84.9%) had TWI in lead aVL and one additional lead. Of the 19 patients who had an MLAD lesion < 50%, 8 patients (42.1%) had TWI in lead aVL and one additional lead. Isolated TWI in lead aVL had an overall sensitivity of 76.7% (95% confidence interval [CI] 0.65-0.86), a specificity of 71.4% (95% CI 0.45-0.88), a positive predictive value of 92%, a negative predictive value of 41.7%, a positive likelihood ratio of 2.7 (95% CI 1.16-6.22), and negative likelihood ratio of 0.32 (95% CI 0.19-0.58) for predicting a MLAD lesion of > 50% (p = 0.0011). CONCLUSIONS: TWI in lead aVL might signify a mid-segment LAD lesion. Recognition of this finding and early appropriate referral to a cardiologist might be beneficial. Additional studies are needed to validate this finding.

Extended tests for evaluating post-traumatic brain injury deficits in resource-limited settings: methods and pilot study data.

Introduction: Traumatic brain injury (TBI) is one of the leading causes of all injury-related deaths and disabilities in the world, especially in low to middle-income countries (LMICs) which also suffer from lower levels of funding for all levels of the health care system for patients suffering from TBI. These patients do not generally get comprehensive diagnostic workup, monitoring, or treatment, and return to work too quickly, often with undiagnosed post-traumatic deficits which in turn can lead to subsequent incidents of physical harm. Methods: Here, we share methods and results from our research project to establish innovative, simple, and scientifically based practices that dramatically leverage technology and validated testing strategies to identify post-TBI deficits quickly and accurately, to circumvent economic realities on the ground in LMICs. We utilized paper tests such as the Montreal cognitive assessment (MoCA), line-bisection, and Bell's test. Furthermore, we combined modifications of neuroscience computer tasks to aid in assessing peripheral vision, memory, and analytical accuracies. Data from seventy-one subjects (51 patients and 20 controls, 15 females and 56 males) from 4 hospitals in Ethiopia are presented. The traumatic brain injury group consists of 17 mild, 28 moderate, and 8 severe patients (based on the initial Glasgow Comma Score). Controls are age and education-matched subjects (no known history of TBI, brain lesions, or spatial neglect symptoms). Results: We found these neurophysiological methods can: 1) be implemented in LMICs and 2) test impairments caused by TBI, which generally affect brain processing speed, memory, and both executive and cognitive controls. Discussion: The main findings indicate that these examinations can identify several deficits, especially the MoCA test. These tests show great promise to assist in the evaluation of TBI patients and support the establishment of dedicated rehabilitation centers. Our next steps will be expansion of the cohort size and application of the tests to other settings.