Cranial Nerve Six Palsy After Vaginal Delivery with Epidural Anesthesia: A Case Report.

BACKGROUND: This case report describes a 34-year-old woman who developed diplopia and strabismus 2 weeks after a vaginal delivery and epidural anesthesia. CASE REPORT: A 34-year-old women presented to the emergency department (ED) with continued headache and new-onset diplopia after having undergone epidural anesthesia for a vaginal delivery 2 weeks prior. During that time, she underwent two blood patches, rested supine, drank additional fluids, and consumed caffeinated products for her spinal headache. When she developed double vision from a cranial nerve VI palsy, she returned to the ED. At that time, she had a third blood patch performed, and she was evaluated by a neurologist. The medical team felt the cranial nerve VI palsy was due to the downward pull of the brain and stretching of the nerve. Magnetic resonance imaging and neurosurgical closure of the dura were considered as the next steps in treatment; however, they were not performed after being declined by the patient. All symptoms were resolved over the next 3 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the uncommon complication of a cranial nerve VI palsy from a persistent cerebrospinal fluid leak after a dural puncture. Emergency physicians must be aware that diplopia can be a rare presenting symptom after patients undergo a lumbar puncture. Furthermore, emergency physicians should be aware of the multiple treatment options available. Knowledge of the timeline of resolution of the diplopia is necessary to make shared decisions with our patients about escalating care.

How Did That Get There? A Case Series of Adolescent Foreign Bodies.

Introduction: Pediatric foreign bodies (FBs) come in many shapes and sizes, and the method by which they enter the body can greatly impact the level of acuity at presentation. Most FBs in children are found in those younger than 5 years old, but the following 3 cases were found in adolescent patients. Case Presentation: We report on 3 adolescent patients who presented to a single community-based emergency department with the chief complaint of abdominal pain and were found to have complications of abdominal FBs. If undiagnosed, the initial indolent courses of FBs can lead to serious complications, as shown in these examples. Conclusion: These cases emphasize the need for physicians to maintain a high level of suspicion, to perform detailed histories, and to consider advanced imaging despite reassuring vital signs or physical examination.

Predicting Complicated Mild Traumatic Brain Injury in Adolescent Trauma to Enhance Clinical Decisions in Imaging.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury algorithm is used to identify children at low risk of clinically significant traumatic brain injuries to reduce computed tomography (CT) exposure. Adapting PECARN rules based on population-specific risk stratification has been suggested to improve diagnostic accuracy. OBJECTIVE: This study sought to identify center-specific patient variables, beyond PECARN rules, that may enhance the identification of patients requiring neuroimaging. METHODS: This single-center, retrospective cohort study was conducted from July 1, 2016, to July 1, 2020, in a Southwestern U.S. Level II pediatric trauma center. The inclusion criteria were adolescents (10-15 years), Glasgow Coma Scale (13-15), with a confirmed mechanical blow to the head. Patients without a head CT were excluded. Logistic regression was performed to identify additional complicated mild traumatic brain injury predictor variables beyond the PECARN. RESULTS: There were 136 patients studied; 21 (15%) presented with a complicated mild traumatic brain injury. Relative to motorcycle collision or all-terrain vehicle trauma (odds ratio [OR] 211.75, 95% confidence interval, CI [4.51, 9931.41], p < .001), an unspecified mechanism (OR 42.0, 95% CI [1.30, 1350.97], p = .03) and consult activation (OR 17.44, 95% CI [1.75, 173.31], p = .01) were significantly associated with complicated mild traumatic brain injury. CONCLUSIONS: We identified additional factors associated with complex mild traumatic brain injury, including motorcycle collision and all-terrain vehicle trauma, unspecified mechanism, and consult activation that are not in the PECARN imaging decision rule. Adding these variables may aid in determining the need for appropriate CT scanning.

A Tale of Two D-Dimers: Comparison of Two Assay Methods to Evaluate Deep Vein Thrombosis or Pulmonary Embolism.

BACKGROUND: D-dimer testing rules out deep vein thrombosis (DVT) and pulmonary embolism (PE) in low-risk emergency department (ED) patients. Most research has measured fibrin-equivalent units (FEUs), however, many laboratories measure D-dimer units (DDUs). OBJECTIVE: Our aim was to determine whether either DDU measurements or FEU measurements can rule out DVT/PE using traditional or age-related cutoff values. METHODS: We performed a de-identified multicenter retrospective evaluation of D-dimer in nonpregnant adult ED patients to evaluate for DVT/PE. DDUs were multiplied by 2 to determine equivalent FEUs prior to analysis. Sensitivity measurements for D-dimer were calculated for FEUs, DDUs, combined FEU/DDUs, and multiple age-adjusted values. RESULTS: We identified 47,088 ED patients with a D-dimer laboratory value (27,307 FEUs/19,781 DDUs) and 1623 DVT/PEs. The median combined FEU/DDU D-dimer was 400 ng/mL FEUs (interquartile range [IQR] 300-900 ng/mL FEUs) for patients without a DVT/PE vs 2530 ng/mL FEU (IQR 1094-6000 ng/mL FEUs) with a DVT/PE (p < 0.001), overall sensitivity of 87.3% (95% confidence interval [CI] 87.0-87.6%) and negative predictive value of 99.3% (95% CI 99.2-99.4%). Individually, FEUs performed better than DDUs, with sensitivities of 88.0% (95% CI 85.8-89.9%) and 86.1% (95% CI 83.1-88.7%), respectively; however, this difference was not statistically significant. Combined age-adjusted performance had a sensitivity of 90.3% (95% CI 88.3-92.0%); however, a new DDU-only age-adjusted criteria had the highest sensitivity of 91.1% (95% CI 87.9-93.6%). CONCLUSIONS: Our undifferentiated D-dimer measurements had a slightly lower sensitivity to rule out DVT/PE than reported previously. Our data support using either DDU or FEU measurements for all ages or when using various age-adjusted criteria to rule out DVT/PE.

The impact of teleneurologists on acute stroke care at an advanced primary stroke centre.

INTRODUCTION: We evaluated the impact of teleneurologists on the time to initiating acute stroke care versus traditional bedside neurologists at an advanced stroke center. METHODS: This observational study evaluated time to treatment for acute stroke patients at a single hospital, certified as an advanced primary stroke centre, with thrombectomy capabilities. Consecutive stroke alert patients between 1 March, 2016 and 31 March, 2018 were divided into two groups based on their neurology consultation service (bedside neurology: 1 March, 2016-28 February, 2017; teleneurology: 1 April, 2017-31 March, 2018). Door-to-tPA time and door-to-IR time for mechanical thrombectomy were compared between the two groups. RESULTS: Nine hundred and fifty-nine stroke patients met the inclusion criteria (436 bedside neurology, 523 teleneurology patients). There were no significant differences in sex, age, or stroke final diagnosis between groups (p > 0.05). 85 bedside neurology patients received tPA and 35 had mechanical thrombectomy, 84 and 44 for the teleneurology group respectively. Door-to-tPA time (median (IQR)) was significantly higher among teleneurology (64 min (51.5-83.5)) than bedside neurology patients (45 min (34-69); p < 0.0001). There was no difference in door-to-IR times (mean ± SD) between bedside neurology (87.2 ± 33.3 min) and teleneurology (90.4 ± 33.4 min; p = 0.67). DISCUSSION: At this facility, our teleneurology services vendor was associated with a statistically significant delay in tPA administration compared with bedside neurologists. There was no difference in door-to-IR times. Delays in tPA administration make it harder to meet acute stroke care guidelines and could worsen patient outcomes.

Cumulative Incidence of Methicillin-Resistant Staphylococcus aureus Colonization in Resident Physicians Over Time.

Background Methicillin-resistant Staphylococcus aureus (MRSA) can colonize up to 14.5% of healthcare workers (HCWs). The colonization rate of HCWs or the hospital setting that contributes most to MRSA colonization is less clear. In this study, we studied new resident physicians (PGY-1), as a model for HCWs, to measure their colonization rate and hypothesized that the incidence of colonization would increase during their first year. Methodology We prospectively enrolled PGY-1 residents of multiple specialties at three academic medical centers. After obtaining informed consent, PGY-1 residents were tested for MRSA in June 2019 before starting any clinical rotations and then retested every three to four months thereafter. The coronavirus disease 2019 pandemic forced us to end the study early. If MRSA-positive, residents were treated with 2% mupirocin and retested for a cure. For comparison, upper-level residents (PGY-2-5) were also enrolled to obtain a baseline prevalence of colonization. Results We enrolled 80 PGY-1 and 81 PGY-2-5 residents in the study. The baseline prevalence of MRSA colonization was 4.94% (4/81) in PGY-2-5 residents and 2.50% (2/80) for new PGY-1 residents; however, this was not statistically significant (p = 0.68). The cumulative yearly incidence of developing MRSA colonization in PGY-1 residents was 4.51%. MRSA colonization was successfully treated in 75% of cases. Conclusions PGY-1 residents had a lower MRSA colonization rate compared to PGY-2-5 residents, although this was not statistically significant. PGY-1 residents had a small incidence of developing MRSA colonization while working in the hospital. Further research is needed to determine if this is clinically relevant to HCWs or their patients.

Emergency Department Utilization and Patient Outcomes During the COVID-19 Pandemic in America.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic precipitated fear of contagion and influenced many people to avoid the emergency department (ED). It is unknown if this avoidance effected overall health or disease mortality. OBJECTIVE: We aimed to quantify the decreased ED volume in the United States, determine whether it occurred simultaneously across the country, find which types of patients decreased, and measure resultant changes in patient outcomes. METHODS: We retrospectively accessed a multihospital, multistate electronic health records database managed by HCA Healthcare to obtain a case series of all patients presenting to an ED during the early COVID-19 pandemic (March 1-May 31, 2020) and the same dates in 2019 for comparison. We determined ED volume using weekly totals and grouped them by state. We also recorded final diagnoses codes and mortality data to describe patient types and outcomes. RESULTS: The weekly ED volume from 160 facilities dropped 44% from 141,408 patients (week 1, March 1-7, 2020) to a nadir of 79,618 patients (week 7, April 12-18, 2020), before rising back to 105,667 (week 13, May 24-30, 2020). Compared with 2019, this overall decline was statistically significant (p < 0.001). The decline was universal across disease categories except for infectious disease and respiratory illnesses, which increased. All-cause mortality increased during the pandemic, especially for those with infectious disease, circulatory, and respiratory illnesses. CONCLUSIONS: The COVID-19 pandemic and an apparent fear of contagion caused a decrease in ED presentations across our hospital system. The decline in ED volume was associated with increased ED mortality, perhaps from delayed ED presentations.

The Influence of Hospital Site on Emergency Physician Press Ganey Scores.

Background: The use of physician satisfaction scores to evaluate emergency medicine physicians' performance and compensation is controversial. Prior studies have shown that the clinical environment may influence scores. This study compared satisfaction scores for the same physician at different emergency departments (ED). Differences in their individual score may indicate the ED environment could be as important as the physician's interaction. Methods: Press Ganey satisfaction scores were obtained for physicians at three EDs-Grand Strand, South Strand and North Strand-between July 2018 and June 2019. Included physicians worked at all 3 facilities and had at least 6 patient satisfaction surveys at each site. The Press Ganey scale ranges from 1-5, with 1 as "very poor" and 5 as "very good". Using top-box methodology, the total physician score was generated from the average of 4 questions: courtesy, keeping patients informed, patient comfort and listening. We utilized descriptive statistics to compare scores for all physicians at each of the 3 sites. In addition, each physician's top box scores were averaged by site for analysis (two-way ANOVA) to determine if individual physician scores varied in different EDs. Results: Fourteen physicians met inclusion criteria. Physicians at the main ED had an average total score of 73.37 ± 6.08 (SD) versus 76.5 ± 8.87 and 85.09 ± 7.75 at the 2 free standing EDs. Two-way ANOVA showed that the Press Ganey scores were significantly different for individual physicians between the newer free-standing ED and either the main ED or the other free-standing ED, p<0.001 and p=0.014, respectively. The observed difference between the main ED and the older free-standing ED was not statistically significant, p=0.111. When applying the same analysis to the 4 individual physician questions, the significant differences or trends persisted. Conclusion: Physician satisfaction scores demonstrated a significant variance depending on where they practiced. The highest patient satisfaction scores were received at the newest of the 3 facilities with individual rooms. The findings suggest that Press Ganey scores may not be reliable when comparing patient satisfaction scores for providers who practice in different EDs.

Clinical Characteristics and Laboratory Biomarkers for Patients with Suspected COVID-19 Infection Within HCA Healthcare.

Background: The coronavirus infection (COVID-19), also known as the Severe Acute Respiratory Syndrome Virus 2 (SARS-CoV-2), caused significant illness and a worldwide pandemic beginning in 2020. Early case reports showed common patient characteristics, clinical variables and laboratory values in these patients. We compared a large population of American COVID-19 patients to see if they had similar findings to these smaller reports. In addition, we examined our population to identify any differences between mild or severe COVID-19 infections. Methods: We retrospectively accessed a de-identified, multi-hospital database managed by HCA Healthcare to identify all adult emergency department (ED) patients that were tested for COVID-19 from January 1st, 2020-April 30th, 2020. We collected clinical variables, comorbidities and laboratory values to identify any differences in those with or without a SARS-CoV-2 infection. Results: We identified 44,807 patients who were tested for SARS-CoV-2. Of those patients, 6,158 were positive for COVID-19. Male patients were more likely to test positive than female ones (15.0% vs. 12.6%, p < 0.001). The most frequently positive tests occurred in age groups 40-49, 50-59 and 60-69 (16.9%, 15.3% and 14.1% respectively). Both African Americans (20.2%) and Hispanics (20.8%) were more likely to test positive than Caucasians (8.3%, p < 0.001). Hypertension and diabetes were more common in those with positive tests, and multiple laboratory biomarkers showed significant differences in severe infections. Conclusions: This broad cohort of American COVID-19 patients showed similar trends in gender, age groups and race/ethnicity as previously reported. Severe COVID-19 disease was also associated with many positive laboratory biomarkers.

Influence of COVID-19 outbreak on emergency department Press Ganey scores of emergency physicians.

Background and Hypothesis: The authors investigate whether there is a difference in Press Ganey (PG; patient satisfaction scores) scores for the emergency physicians before and during the coronavirus disease 2019 (COVID-19) outbreak at a regional group of emergency departments in the southeastern United States. The authors hypothesize that decreases in emergency department volume, less emergency department boarding of admissions, reduced use of hallway beds, and favorable attitudes toward emergency physicians during the COVID-19 outbreak may influence patient satisfaction scores measured in the Press Ganey surveys. Study Design and Methods: The authors performed a retrospective review of PG scores obtained over the prior 7 months at 8 larger teaching hospitals in the Southeast region (Florida, Georgia, and South Carolina). Averaged physician PG Scores and their 4 components-courtesy, time to listen, informative regarding treatment, concern for comfort-were collected. The authors evaluated the overall physician PG ratings for March through May 2020 (COVID outbreak) vs the prior 4 months. Overall emergency physician scores, using top box methodology of percent highest response, were averaged from 4 questions regarding the emergency physician's care. Results: There were 6272 patient satisfaction surveys returned in the 7-month study period; 4003 responses during the pre-COVID months (November 2019-February 2020) and 2296 during the COVID months (March through May 2020). Results showed that in the "pre-COVID time" the PG surveys scored in the 17% of all PGs in the country (63.9% "top-box" or highest rating score) as compared to scoring in the 34% of all PGs (68.1% "top-box") during "COVID time." These data were statistically significant using a chi-square analysis with P < 0.001. Conclusions: Emergency physician patient satisfaction scores, as represented by the PG score, were significantly higher during the COVID months, in comparison to the pre-COVID months, for 8 teaching hospitals in the Southeast region of the United States.

Presentation Times of Myocardial Infarctions to the Emergency Department: Disappearance of the Morning Predominance.

BACKGROUND: Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning. OBJECTIVES: We hypothesized that there no longer is a morning predominance of MI, and that the timing of ST-elevation myocardial infarction (STEMI) vs. non-ST-elevation myocardial infarction (NSTEMI) presentation differs. METHODS: We reviewed MI, STEMI, and NSTEMI patients (2013-2017) from a multiple-hospital system, identified by diagnostic codes. Daily emergency department arrival times were categorized into variable time intervals for count and proportional analysis, then examined for differences. RESULTS: There were 18,663 MI patients from 12 hospitals included in the analysis. Most MIs occurred between 12:00 pm and 5:59 pm (35.7%), and least between 12:00 am-5:59 am (16.3%). After subdividing all MIs into STEMIs and NSTEMIs, both groups continued to have the greatest presentation between 12:00 pm and 5:59 pm (33.1% and 36.0%, respectively). STEMIs (17.2%) and NSTEMIs (16.2%) were least frequent between 12:00 am and 5:59 am. We found the second most common presentation time for MIs was in the 6 pm-11:59 pm time period, which held true for both subtypes (MI 26.7%, STEMI 26.4%, NSTEMI 26.7%). CONCLUSIONS: These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.

Prehospital Antibiotics Improve Morbidity and Mortality of Emergency Medical Service Patients with Sepsis.

Background: Severe sepsis is a major cause of mortality in patients evaluated in the Emergency Department (ED). Early initiation of antibiotic therapy and IV fluids in the ED is associated with improved outcomes. We investigated whether early administration of antibiotics in the prehospital setting improves outcomes in these patients with sepsis. Methods: This is a retrospective study comparing outcomes of patients meeting sepsis criteria in the field by EMS, who were treated with IV fluids and antibiotics. Their outcomes were compared with controls where fluids were administered prehospital and antibiotics were initiated in the ED. We compared morbidity and mortality between these groups. Results: Early antibiotics and fluids were demonstrated to show significant improvement in outcomes in the patients meeting sepsis criteria treated in the pre-hospital setting. The average age for sepsis patients receiving antibiotics in the prehospital setting was statistically higher than that for patients in the historical control group, 73.23 years and 67.67, respectively (p < 0.036), and there was no statistically significant difference of Charlson Comorbidity Index between the groups (p two-tail = 0.28). Average intensive care unit length of stay was 2.51 days in the in the prehospital group and 5.18 days in the historical controls, and the prehospital group received fewer blood products than the historical controls (p = 0.0003). Conclusions: Early IV administration of antibiotics in the field significantly improves outcome in EMS patients who meet sepsis criteria based on a modified qSOFA score.

Intravenous overdose of insulin glargine without prolonged hypoglycemic effects.

BACKGROUND: Insulin glargine is a long-acting insulin that can cause prolonged hypoglycemia when misdosed or overdosed subcutaneously. There are no reports of intravenous overdoses of insulin glargine. OBJECTIVES: We present a case of a patient inadvertently given a large intravenous dose of insulin glargine (100 units) who had an unremarkable course. CASE REPORT: A 46-year-old woman with a history of type 2 diabetes was found to be hyperglycemic and was mistakenly given an intravenous bolus of 100 units of insulin glargine. She did not become hypoglycemic, did not require parenteral dextrose, and her blood sugar readings stabilized within 3 h. She was admitted and observed for 17 h and discharged without complication. CONCLUSION: To our knowledge, this is the first report of a significant intravenous insulin glargine administration. This patient had an unremarkable course and recovered without any parenteral glucose. This case, along with prior studies on healthy volunteers, suggests that unlike subcutaneous overdoses, intravenous insulin glargine misdose/overdose may not need prolonged observation; an observation time of 6 h may be sufficient in these patients.

Protein C as an early biomarker to distinguish pneumonia from sepsis.

PURPOSE: Patients with pneumonia often are unrecognized as also having sepsis. We evaluated protein C, as a potential biomarker, to differentiate between patients with pneumonia and sepsis. MATERIALS AND METHODS: A retrospective chart review was performed for all protein C tests over a 14-month period (January 11, 2007, to March 10, 2008) at an 8-hospital system with 1706 total beds. Charts were screened for the discharge diagnoses of sepsis, severe sepsis, septic shock, bacteremia, and pneumonia. Protein C levels were compared between patients with sepsis and pneumonia, and at time intervals of 0 to 12 hours, 12 to 24 hours, 24 to 48 hours, and more than 48 hours after diagnosis. RESULTS: One thousand forty-seven protein C levels were obtained in 980 patients. Thirty-two protein C levels met the inclusion and exclusion criteria for the sepsis group, and 34 for the pneumonia group. Overall, the mean protein C levels were significantly less in patients with sepsis at 59.2% (95% confidence interval [CI], 49.5%-68.9%) compared with patients with pneumonia at 108.9% (95% CI, 95.6%-122.3%; P < .001). In addition, levels within each of the time intervals were also significantly lower in the sepsis group. CONCLUSIONS: In this study, protein C levels performed well in differentiating between patients with sepsis or pneumonia in the early period after diagnosis.

Middle ear pressure and symptoms after skydiving.

OBJECTIVES: Altitude-related otic barotrauma and its symptoms have been identified from air-travel, scuba diving, and hyperbaric chambers, but not in skydiving. It is not known whether skydiving-related otic barotrauma could cause symptoms severe enough for medical attention or be implicated in skydiving-related accidents. This study assessed the effect of altitude change on middle ear pressures in skydivers by comparing changes in pressure before and after a skydive, pressure changes in those who developed middle ear symptoms vs. those who did not, and pressures in those who attempted equalization vs. not. METHODS: This prospective observational cohort enrolled skydivers on random days in Deland, FL. A tympanometer was used to measure middle ear pressures in decapascals (daPa) on the ground before and after skydiving. RESULTS: Average middle ear pressures in 69 subjects were significantly different before (-23.5 daPa) and after (-70.5 daPa) the skydive. There were 13 subjects (18.8%) who had middle ear symptoms after descent, but there were no statistically significant differences in ear pressure changes in those with (-57.5 daPa) and without (-44.2 daPa) symptoms after their jump. There was, however, a significant difference in pressure in those jumpers who did (-32.7 daPa) and did not (-75.7 daPa) equalize successfully after their jump. CONCLUSIONS: Rapid skydiving descent from high altitudes causes negative middle ear pressure changes. The ability to equalize ear pressures after a jump had a large impact on the change in ear pressure. However, the change in middle ear pressure was not associated with the presence of middle ear symptoms.