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.

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.

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.

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).

Follow up for emergency department patients after intravenous contrast and risk of nephropathy.

INTRODUCTION: Contrast-induced nephropathy (CIN), defined as an increase in serum creatinine (SCr) greater than 25% or ≥0.5 mg/dL within 3 days of intravenous (IV) contrast administration in the absence of an alternative cause, is the third most common cause of new acute renal failure in hospitalized patients. It is known to increase in-hospital mortality up to 27%. The purpose of this study was to investigate the rate of outpatient follow up and the occurrence of CIN in patients who presented to the emergency department (ED) and were discharged home after computed tomography (CT) of the abdomen and pelvis (AP) with IV contrast. METHODS: We conducted a single center retrospective review of charts for patients who required CT of AP with IV contrast and who were discharged home. Patients' clinical data included the presence of diabetes mellitus, hypertension, chronic kidney disease (CKD) and congestive heart failure (CHF). RESULTS: Five hundred and thirty six patients underwent CT of AP with IV contrast in 2011 and were discharged home. Diabetes mellitus was documented in 96 patients (18%). Hypertension was present in 141 patients (26.3%), and 82 patients (15.3%) were on angiotensin-converting-enzyme inhibitors (ACEI). Five patients (0.9%) had documented CHF and all of them were taking furosemide. Seventy patients (13%) had a baseline SCr >1.2 mg/dL. One hundred fifty patients (28%) followed up in one of the clinics or the ED within one week after discharge, but only 40 patients (7.5%) had laboratory workup. Out of 40 patients who followed up within 1 week after discharge, 9 patients (22.5%) developed CIN. One hundred ninety patients (35.4%) followed up in one of the clinics or the ED after 7 days and within 1 month after discharge, but only 71 patients (13.2%) had laboratory workup completed. Out of 71 patients who followed up within 1 month, 11 patients (15%) developed CIN. The overall incidence of CIN was 15.3% (17 out of 111 patients). CONCLUSION: There was a poor outpatient follow up after CT of AP with IV contrast and biochemically CIN appears to be present in some patients. Unlike previous reports that CKD is the major risk factor for CIN, our results demonstrated that risk factors such as advanced age, DM and hypertension seem to predispose patients to CIN rather than abnormal baseline SCr. [West J Emerg Med. 2014;15(3):276-281.].

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.

Vogt-Koyanagi-Harada disease: presentation and implications in undocumented immigrants.

Vogt-Koyanagi-Harada syndrome is an autoimmune disease involving pigmented tissue in the eyes, auditory system, skin, and central nervous system. It often presents as bilateral chronic granulomatous panuveitis. We report the case of a 32-year-old immigrant who presented to the emergency department asking for a second opinion for loss of vision and progressive hearing loss. We also will discuss the issue limited access to health care for a vulnerable population such as undocumented immigrants.

A novel calpain inhibitor for treatment of transient retinal ischemia in the rat.

After an acute ischemia/reperfusion of the rat retina, the activation of cytotoxic proteases, including calpain, results in necrosis and apoptosis of retinal ganglion cells resulting in their degeneration. Using a systemically administered calpain inhibitor that crosses the blood-retinal barrier would provide for novel systemic intervention that protects the retina from acute injury and loss of function. Herein, we study a novel calpain peptide inhibitor, cysteic-leucyl-argininal (CYLA), in an in-vivo rat model of retinal ischemia to determine functional protection using electroretinography. The CYLA prodrug was administered intraperitoneally before and/or after ischemia-reperfusion at concentrations of 20-40 mg/kg. We found that administering 20 mg/kg of CYLA only after ischemia provides significant preservation of retinal function.