A Randomized Control Trial of Cardiopulmonary Feedback Devices and Their Impact on Infant Chest Compression Quality: A Simulation Study.

OBJECTIVES: In effort to improve chest compression quality among health care providers, numerous feedback devices have been developed. Few studies, however, have focused on the use of cardiopulmonary resuscitation feedback devices for infants and children. This study evaluated the quality of chest compressions with standard team-leader coaching, a metronome (MetroTimer by ONYX Apps), and visual feedback (SkillGuide Cardiopulmonary Feedback Device) during simulated infant cardiopulmonary resuscitation. METHODS: Seventy voluntary health care providers who had recently completed Pediatric Advanced Life Support or Basic Life Support courses were randomized to perform simulated infant cardiopulmonary resuscitation into 1 of 3 groups: team-leader coaching alone (control), coaching plus metronome, or coaching plus SkillGuide for 2 minutes continuously. Rate, depth, and frequency of complete recoil during cardiopulmonary resuscitation were recorded by the Laerdal SimPad device for each participant. American Heart Association-approved compression techniques were randomized to either 2-finger or encircling thumbs. RESULTS: The metronome was associated with more ideal compression rate than visual feedback or coaching alone (104/min vs 112/min and 113/min; P = 0.003, 0.019). Visual feedback was associated with more ideal depth than auditory (41 mm vs 38.9; P = 0.03). There were no significant differences in complete recoil between groups. Secondary outcomes of compression technique revealed a difference of 1 mm. Subgroup analysis of male versus female showed no difference in mean number of compressions (221.76 vs 219.79; P = 0.72), mean compression depth (40.47 vs 39.25; P = 0.09), or rate of complete release (70.27% vs 64.96%; P = 0.54). CONCLUSIONS: In the adult literature, feedback devices often show an increase in quality of chest compressions. Although more studies are needed, this study did not demonstrate a clinically significant improvement in chest compressions with the addition of a metronome or visual feedback device, no clinically significant difference in Pediatric Advanced Life Support-approved compression technique, and no difference between compression quality between genders.

Effect of Emergency Physician-Performed Point-of-Care Ultrasound and Radiology Department-Performed Ultrasound Examinations on the Emergency Department Length of Stay Among Pregnant Women at Less Than 20 Weeks' Gestation.

OBJECTIVES: We sought to confirm retrospective studies that measured an approximately 20% reduction in emergency department (ED) length of stay (LOS) in early-gestation pregnant women who receive emergency physician-performed point-of-care ultrasound (US) examinations rather than radiology department-performed US examinations for evaluation of intrauterine pregnancy (IUP). METHODS: A randomized controlled clinical trial was performed at an urban academic safety net hospital and 2 Naval medical centers in the United States. The allocation was concealed before enrollment. Clinically stable adult pregnant women at less than 20 weeks' gestation who presented to the ED with abdominal pain or vaginal bleeding were randomized to receive a point-of-care or radiology US to assess for IUP. The primary outcome measure was the ED LOS. RESULTS: A total of 224 patients (point-of-care US, n = 118; radiology US, n = 106) were included for the analysis. The ED LOS was 20 minutes shorter in the point-of-care US arm (95% confidence interval [CI], -54 to 7 minutes). Adjusting for variability due to the location, the ED LOS was calculated to be 31 minutes shorter (95% CI, -64 to 1 minute) than for patients in the radiology US arm. Excluding patients in the point-of-care US arm who crossed over to radiology US after an inconclusive point-of-care US examination, the ED LOS was 75 minutes shorter than in the radiology US arm (95% CI, -97 to -53 minutes). CONCLUSIONS: Early-gestation pregnant ED patients requiring pelvic US were discharged earlier when point-of-care US was used rather than radiology US; however, this trial did not achieve our target of 30 minutes. Nevertheless, our data support the routine use of ED point-of-care US for IUP, saving the most time if a conclusive IUP is identified.

A Uniquely Abnormal Stool Specimen: A Case Report.

BACKGROUND: Autoamputation of the appendix is a condition associated with the Ladd's procedure, a pediatric surgical technique for correction of intestinal malrotation. A 4-year-old male patient with a history of a Ladd's procedure performed as a newborn was brought in by his mother for "passing intestine" just prior to arrival. She reported that for several weeks her son had intermittent, crampy abdominal pain that resolved after the unusual-appearing bowel movement. After reviewing an image of the bowel movement, and in consultation with pediatric surgery, it was concluded that the patient had passed a devascularized appendix in his stool immediately prior to arrival. CASE REPORT: A 4-year-old boy with a past medical history of heterotaxy syndrome (inversion of the thoraco-abdominal organs), a double outlet right ventricle, and Ladd's procedure presented to the Emergency Department (ED) after "passing intestine" in his stool. Close examination of the photo demonstrated a tubular structure with taenia, consistent with an appendix. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Autoamputation of the appendix is an uncommon presentation in the ED. Passing a devascularized appendix is a benign condition and can present with weeks of intermittent abdominal pain that resolves with passage of appendix in the stool. Remnants of the appendix can remain within the intestinal lumen years after the Ladd's procedure. Emergency physicians with a general awareness of this rare phenomenon can confidently make the diagnosis and reassure worried parents.

Case Report: Not All Genital Ulcers Are Herpetic.

BACKGROUND: The most common cause of genital lesions is herpes simplex virus (HSV) (Pediatr Dermatol. 2012;29:147-153). However, in children and adolescents who are not sexually active, several other causes need to be considered. CASE: A 13-year-old adolescent girl presented to the emergency department with genital lesions. A gynecologist was consulted at time of presentation for concerns of a primary HSV infection and concurred. Final HSV and sexually transmitted infection testing were subsequently negative. At outpatient follow-up, a child abuse pediatrician made the diagnosis of aphthous genital ulcers (AGUs). Awareness of the diagnosis of AGUs is important because alternate diagnoses such as HSV could imply child abuse. It is critical to include AGUs in the differential diagnosis and to provide the appropriate referrals.

Respiratory Failure in a Child Due to Type 2 Postobstructive Pulmonary Edema.

BACKGROUND: Postobstructive pulmonary edema (POPE), sudden pulmonary edema after upper airway obstruction, is an important disease entity for pediatric emergency physicians to recognize and initiate prompt treatment. Type 1 POPE occurs after a sudden, severe upper airway obstruction, whereas type 2 POPE develops after acute relief of chronic airway obstructive. CASE: A 12-year-old boy, with a history of untreated sleep apnea, on postoperative day 2 from appendectomy, was brought to the emergency department in respiratory distress. The patient required urgent intubation, and copious pink frothy fluid was suctioned from the endotracheal tube. He was initially difficult to oxygenate, but with ventilator setting changes including a high positive end-expiratory pressure, the patient improved. He was discharged on hospital day 3 with nighttime BiPAP for home use. CONCLUSIONS: Type 2 POPE should be considered in a patient presenting with respiratory distress and a history of sleep apnea. Optimal ventilator management includes use of PEEP in the 10 to 15 cm H2O range. The roles of diuretics and steroids are controversial. Most patients will do well after a brief period of ventilatory support (24-48 hours). With the rise of ambulatory surgery, pediatric emergency physicians must be attuned to both the surgical and anesthetic complications that occur in the early postoperative period.

Acute vision loss: a fuzzy presentation of sarcoidosis.

BACKGROUND: Acute vision loss is a devastating problem for patients and a challenging diagnostic dilemma for Emergency Physicians. This chief complaint is one in which we must be adept at quickly evaluating and initiating either care or referral. OBJECTIVES: This case reviews the approach to acute vision loss and shows the importance of expanding the differential in atypical and complex presentations. CASE REPORT: A 31-year-old, previously healthy, white woman presented to the Emergency Department (ED) with 1 day of painless right eye vision loss. Ocular ultrasound and slit-lamp examination were unremarkable. Fundoscopic examination revealed retinal hemorrhages and papillitis. Her chest X-ray study was significant for bilateral hilar adenopathy, and subsequent lymph node biopsy confirmed the diagnosis of sarcoidosis. CONCLUSIONS: Although sarcoidosis is more common in African Americans, it must be considered in all patients in the appropriate clinical context. Sarcoidosis is an important diagnosis to include on the differential of many chief complaints that present to the ED, including acute vision loss and dyspnea.

An Ethical Framework for Conducting Active-Shooter Simulation in the Healthcare Environment.

SUMMARY STATEMENT: Active shooter events, although rare, are increasing in frequency in the United States, and healthcare settings are not immune to such events. Of the 277 active shooter events that took place in the United States between 2000 and 2019, 15 (4.5%) took place in healthcare facilities. Healthcare workers (HCWs) must be (1) well trained to respond to an active shooter event and (2) trained to respond to active shooter casualties. Educational activities related to active shooter events require a clear focus on goals and objectives, balanced to assure the physical and psychological safety of all participants. This article outlines how the recommendations of the National Association of School Psychologists might be adapted to conduct active shooter drills in the healthcare setting. This approach provides a framework for managing some of the ethical considerations in active shooter simulations.

Valentino's Syndrome: A Life-Threatening Mimic of Acute Appendicitis.

Perforated ulcers are a rare cause of abdominal pain, and may not be considered when pain is localized to the right lower quadrant (RLQ). This case highlights an unusual presentation of a perforated duodenal ulcer that presented with RLQ pain, which has been described as Valentino's syndrome. Valentino's syndrome occurs when gastric or duodenal fluids collect in the right paracolic gutter causing focal peritonitis and RLQ pain. This case highlights that perforated ulcers, while an uncommon cause of RLQ pain, must remain on the differential of any patient that has an abdominal examination consistent with peritonitis.

Cervical Artery Dissection and Choosing Appropriate Therapy.

Cervical artery dissection is a common cause of stroke in young adults. This may result from head and neck trauma; it can also occur spontaneously or secondary to genetic connective tissue or vascular disorders. Neurologic symptoms arise as a result of thromboembolism and hypoperfusion causing cerebral ischemia. We present a case of a previously healthy male who was found to have a cervical internal carotid artery dissection and the decision to use antiplatelet therapy instead of anticoagulation to prevent stroke. Data is lacking regarding the efficacy of one therapy over the other.