Stimulant-related Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy (TC) is a rare but increasingly recognized mimic of acute coronary syndrome. Patients present with angina,ST-segment changes on electrocardiogram (both elevations and depressions),and rapid rises in cardiac biomarkers. Many kinds of stressful events have been associated with TC, but only a handful of drug-related cases have previously been reported. We describe the case of a 58-year-old woman who developed TC 2 days after crack cocaine use, a diagnosis first suggested as bedside echocardiography in the emergency department.Recognition of the classic echocardiographic appearance of TC­apical hypokinesis causing "ballooning" of the left ventricle during systole­may greatly assist providers in the early identification of this condition.

Ultrasound-guided forearm nerve blocks in kids: a novel method for pain control in the treatment of hand-injured pediatric patients in the emergency department.

OBJECTIVES: Ultrasound-guided forearm nerve blocks have been shown to safely reduce pain for emergency procedures in the adult emergency department (ED). Although ultrasonography is widely used for forearm nerve blocks in the adult ED and in the pediatric operating room, no study to date has examined its use in the pediatric emergency setting. METHODS: We conducted a prospective nonblinded descriptive study of ultrasound-guided ulnar, median, and radial nerve blocks in a convenience sample of pediatric patients with hand injuries requiring procedural intervention who presented to a freestanding pediatric ED. RESULTS: The mean initial pain score for the sample was 5.8, and the mean postprocedure score was 0.8, with a mean on the 10-point visual pain scale of 5 (interquartile range [IQR], 3-6; P = 0.04). Seven patients reported complete resolution of their pain that was signified by a score of 0. The mean time to completion for ulnar nerve block was 79 seconds (IQR, 67-103 seconds). The mean time to completion for median nerve block was 76 seconds (IQR, 70-112 seconds). The mean time to completion for radial nerve block was 69 seconds (IQR, 60-100 seconds). No immediate complications, including vascular puncture, carpal tunnel injury, or direct nerve injection, were noted during the study. At 1-year follow-up, no adverse effects were reported. CONCLUSIONS: Ultrasound-guided forearm nerve blocks are effective for pediatric patients in the ED. The procedure provides effective analgesia and facilitates care while minimizing iatrogenic risk.

Identification of high-risk patients with acute coronary syndrome using point-of-care echocardiography in the ED.

Stratifying risk of patients with acute coronary syndrome (ACS) in the emergency department (ED) remains a frequent challenge. When ST-elevation criteria are absent, current recommendations rely upon insensitive and time-intensive methods such as the electrocardiogram and cardiac enzyme testing. Here, we report on a series of cases, where emergency physicians used a simplified model for identifying regional wall motion abnormalities by point-of-care echocardiography in patients presenting with chest pain to the ED. With the use of a simplified model described herein, high-risk patients with ACS were identified rapidly in a cohort usually difficult to risk stratify.

Rural family physician use of point-of-care ultrasonography: experiences of primary care providers in British Columbia, Canada.

BACKGROUND: In British Columbia (BC), rural and remote areas lack proximal access to radiographic services. Poor access to radiographic services in rural settings presents a challenge to timely diagnosis and screening across many disease states and healthy pregnancies. As a solution to the lack of access to radiographic services in rural settings, the Rural Coordination Centre of BC (RCCbc) supported rural Family Physicians (FPs) wishing to use PoCUS through the Intelligent Network for PoCUS (IN PoCUS) program. This study evaluates FPs' experience and use of PoCUS in their clinical practice. METHODS: This qualitative study conducted in-depth virtual interviews with 21 FPs across rural BC. The interview asked participants' motivation to participate in the RCCbc program, the type of training they received, their current use of PoCUS, their experience with the technology, and their experience interacting with specialists in regional centres. Thematic analysis of findings was undertaken. RESULTS: This study used Rogers' framework on the five elements of diffusion of innovation to understand the factors that impede and enable the adoption of PoCUS in rural practice. Rural FPs in this study differentiated PoCUS from formal imaging done by specialists. The adoption of PoCUS was viewed as an extension of physical exams and was compatible with their values of providing generalist care. This study found that the use of PoCUS provided additional information that led to better clinical decision-making for triage and allowed FPs to determine the urgency for patient referral and transport to tertiary hospitals. FPs also reported an increase in job satisfaction with PoCUS use. Some barriers to using PoCUS included the time needed to be acquainted with the technology and learning how to integrate it into their clinical flow in a seamless manner. CONCLUSION: This study has demonstrated the importance of PoCUS in improving patient care and facilitating timely diagnosis and treatment. As the use of PoCUS among FPs is relatively new in Canada, larger infrastructure support such as improving billing structures, long-term subsidies, educational opportunities, and a quality improvement framework is needed to support the use of PoCUS among rural FPs.

The ultrasound-guided superficial cervical plexus block for anesthesia and analgesia in emergency care settings.

The ultrasound-guided superficial cervical plexus (SCP) block may be useful for providers in emergency care settings who care for patients with injuries to the ear, neck, and clavicular region, including clavicle fractures and acromioclavicular dislocations. The SCP originates from the anterior rami of the C1-C4 spinal nerves and gives rise to 4 terminal branches--greater auricular, lesser occipital, transverse cervical, and suprascapular nerves--that provide sensory innervation to the skin and superficial structures of the anterolateral neck and sections of the ear and shoulder. Here we describe an ultrasound-guided technique for blockade of the SCP that is potentially well suited to emergency care settings. We present the first case description of its successful use to manage pain for a patient with an acute clavicle fracture. This case is presented to highlight one of several potential applications of this promising new technique in the emergency department.

Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma.

A 3-month-old infant girl was transferred to our emergency department (ED) with a subtrochanteric femoral neck fracture due to nonaccidental trauma. She received multiple doses of parenteral analgesics both before arrival and in our ED. We performed an ultrasound-guided femoral nerve block using 2.0 mL of 0.25% bupivicaine (approximately 1.25 mg/kg) before placing the patient in a Pavlik harness. Successful pain control was achieved within 15 minutes of the procedure allowing pain-free manipulation of the affected extremity. The patient required only a single dose of parenteral narcotics during the ensuing 18 hours. To our knowledge, this is the first report of an ultrasound-guided femoral nerve block used in the ED for pain control in a pediatric patient.

Supracondylar radial nerve block for treatment of distal radius fractures in the emergency department.

BACKGROUND: Patients with acute distal radius fractures are frequently treated in the emergency department (ED) with closed reduction and splinting. Many of the anesthesia methods frequently employed may either lack efficacy or require additional monitoring and resources. CASE REPORT: An 18-year-old woman presented to the ED with a dorsally angulated distal radius fracture (Colles fracture). As an alternative to procedural sedation, an ultrasound-guided block of the radial nerve proximal to its bifurcation into the deep and superficial branches was performed. The resulting anesthesia was adequate to reduce and splint the fracture with minimal discomfort for the patient. CONCLUSION: Ultrasound-guided supracondylar block of the radial nerve proximal to the origin of the deep and superficial branches provides safe and efficacious anesthesia for distal radius fracture reduction in the ED.

From the heart: interatrial septal aneurysm identified on bedside ultrasound.

A 61 year-old man presented to the Emergency Department for one day of nonspecific chest pain. Bedside echocardiogram performed by the emergency physician revealed normal systolic cardiac function but also showed a large ( > 10mm) bicornuate interatrial septal aneurysm (IASA) projecting into the right atrium (Figure 1, Video 1). There was no evidence of intraatrial thrombus. A formal echocardiogram performed later that day confirmed the diagnosis and also detected a patent foramen ovale (PFO) with a left-to-right shunt that reversed with Valsalva maneuver.

Evidence-Based Emergency Management Of The Pediatric Airway.

Pediatric airway emergencies are rare, yet they are anxiety-provoking events that can occur in both pediatric and general emergency departments. Several novel concepts regarding preoxygenation during rapid sequence intubation, anticipation and prevention of intubation-related complications, the utility of premedication agents, and the selection of induction and paralytic agents have been highlighted in recent clinical trials and review articles. In this review, we analyze the data behind these concepts, highlight current pediatric literature related to these issues, and present reasonable conclusions based on the best available evidence. We begin with an analysis of the anatomic and physiologic differences commonly encountered in the pediatric patient during rapid sequence intubation, and we then review a systematic approach to the assessment of the pediatric patient in respiratory distress (ie, the pediatric assessment triangle) and conclude with a simple approach to pediatric rapid sequence intubation, starting with the preparatory phase and ending with postintubation management. We additionally highlight several alternative airway devices and discuss special situations, including rapid sequence intubation in the obese pediatric patient and in the difficult airway patient.

A phenomenology of the 'placebo effect': taking meaning from the mind to the body.

Most mainstream attempts to understand the "placebo effect" invoke expectancy theory, arguing that expecting certain outcomes from a treatment or intervention can manifest those outcomes. Expectancy theory is incompatible with the phenomena of placebo responses, more appropriately named "meaning responses." The expectancy account utilizes reflexive consciousness to connect a world of conceptual representations to mechanical physiology. An alternative account based upon Merleau-Ponty's motor intentionality argues that the body understands and is capable of responding to meanings without the need for any conceptual or linguistic content. A motor intentional framework of meaning poses dramatic implications for the interpretation of clinical trials and in the clinical practice of medicine. Most strongly, it argues that the empathic physician can facilitate the physiologic effects of treatments through skillful participation and manipulation of the meaning response.