Hemolyzed Laboratory Specimens in the Emergency Department: An Underappreciated, but Frequent Problem.

INTRODUCTION: Hemolysis of blood samples from emergency department (ED) patients leads to delays in treatment and disposition. The aim of this study is to determine the frequency of hemolysis and variables predictive of hemolysis. METHODS: This observational cohort study was conducted among three institutions: academic tertiary care center and two suburban community EDs, with an annual census of over 270,000 ED visits. Data were obtained from the electronic health record. Adults requiring laboratory analysis with at least one peripheral intravenous catheter (PIVC) inserted within the ED were eligible. Primary outcome was hemolysis of lab samples and secondary outcomes included variables related to PIVC failure. RESULTS: Between January 8, 2021 and May 9, 2022, 141,609 patient encounters met inclusion criteria. The average age was 55.5 and 57.5% of patients were female. Hemolysis occurred in 24,359 (17.2%) samples. In a multivariate analysis, when compared to 20-gauge catheters, smaller 22-gauge catheters had an increased odds of hemolysis (OR 1.78, 95% confidence interval (CI) 1.65-1.91; P < .001), while larger 18-gauge catheters had a lower odds of hemolysis (OR 0.94; 95% CI 0.90-0.98; P = .0046). Additionally, when compared to antecubital placement, hand/wrist placement demonstrated increased odds of hemolysis (OR 2.06; 95% CI 1.97-2.15; P < .001). Finally, hemolysis was associated with a higher rate of PIVC failure (OR 1.06; 95%CI 1.00-1.13; P = 0.043). DISCUSSION: This large observational analysis demonstrates that lab hemolysis of is a frequent occurrence among ED patients. Given the added risk of hemolysis with certain placement variables, clinicians should consider catheter gauge/placement location to avoid hemolysis that may result in patient care delays and prolonged hospital stays.

Emergency Department Doppler Assessment of a Central Retinal Artery Occlusion: Case Report.

Introduction: Vision loss is a symptom found frequently in patients presenting to the emergency department (ED). Central retinal artery occlusion (CRAO) is an uncommon yet time-sensitive and critical cause of painless vision loss in which delayed diagnosis can lead to significant morbidity. Emergency medicine literature documents the ability to diagnose a CRAO using ultrasound by identifying the hyperechoic thrombus-coined the retrobulbar spot sign. Case Report: We present the case of a patient presenting with painless monocular vision loss for which CRAO was diagnosed in the ED using point-of-care ultrasound enhanced by the utilization of serial Doppler examinations as well as calculation of the central retinal artery resistive index. Conclusion: Despite the pre-existing literature on point-of-care ultrasound investigation of central retinal artery occlusion, there are no emergency medicine case reports describing serial examination of the central retinal artery by spectral Doppler or calculation of arterial resistive index to improve this evaluation and monitor progression of the pathology.

Acute Myeloid Leukemia: A "Head to Toe" Examination.

Acute myeloid leukemia (AML) is a hematologic malignancy that can affect all blood cell lineages, the presentation varies, and infection is a common complication. This case involves a patient initially presenting with a necrotic foot ulcer and leukocytosis, ultimately leading to a diagnosis of osteomyelitis. After establishing adequate source control with serial debridements and intravenous antibiotics, the patient developed some knee swelling. On repeat assessment, he was discovered to have lymphadenopathy, and workup revealed AML. As indicated by this case, though it appeared a clear-cut diagnosis of osteomyelitis, there was an underlying malignancy that would have potentially gone unnoticed due to incomplete clinical examination.