Pediatric firearm injuries to the extremity: management in the emergency department.

Firearm injuries are a leading cause of pediatric mortality in the United States. The frequency of pediatric extremity firearm injuries and the high repeat incidence in high-risk patients make it important for emergency clinicians to understand how to manage these injuries. This issue focuses on the acute management of firearm injuries to the extremities of pediatric patients, drawing from the pediatric literature or extrapolated from adult literature where pediatric evidence is scarce. Current trends, novel management, and controversies are also discussed.

Using Point-of-Care Ultrasound to Expedite Diagnosis of Necrotizing Fasciitis: A Case Report.

It is vital that all emergency medicine physicians (EP) are able to perform and evaluate point-of-care ultrasound (POCUS) images when a patient's presentation is concerning for necrotizing fasciitis (NF). We present a case of a 69-year-old man who had initially presented to an outside hospital with testicular edema and difficulty urinating. Consultative ultrasound was interpreted as a hydrocele and bilateral scrotal pearls but failed to identify the sonographic hallmarks of NF (subcutaneous thickening, free fluid, and subcutaneous air). Computed tomography (CT) performed several hours later re-demonstrated free air and fascial thickening in the scrotum prompting transfer to our hospital for a higher level of care. Upon arrival to our emergency department (ED) POCUS showed extensive free air with shadowing, thickened subcutaneous tissue, and fluid collections. The patient was immediately evaluated by general surgery and urology, who took him to the operating room for debridement. This case highlights the challenges EP face when assessing patients with NF. Early-on, clinical findings can be subtle and easily missed. POCUS can aid in the diagnosis of this time-dependent disease process. Therefore, it is paramount that EPs look for and recognize characteristic sonographic findings present in NF to improve the accuracy and timeliness of the diagnosis. Topics: Point-Of-Care Ultrasound, necrotizing fasciitis.

Zoster meningitis in an immunocompetent host with headache and atypical rash.

Headache is a frequent emergency department (ED) complaint. Secondary headache, due to infectious causes, must be carefully evaluated as a differential diagnosis. Red flag signs and classic physical examination findings are available to aid the diagnosis and evaluation of secondary headache. These findings, however, are limited by poor sensitivity and predictive value. We present a case of Herpes zoster (HZ) meningitis in a young healthy male adult with major presenting symptom of headache and new-onset rash to underscore the variation in atypical presentations of aseptic meningitis. HZ-associated aseptic meningitis often presents with characteristic, but at times atypical rash. We recommend skin lesions be thoroughly evaluated, along with classic signs of fever and nuchal rigidity, to assist in the diagnosis of meningitis.

Excess Out-Of-Hospital Mortality and Declining Oxygen Saturation: The Sentinel Role of EMS Data in the COVID-19 Crisis in Tijuana, Mexico.

OBJECTIVE: Emergency medical services (EMS) may serve as a key source of real-time data about the evolving health of COVID-19 affected populations, especially in low-and-middle-income countries (LMICs) with less rapid and reliable vital statistic registration systems. Although official COVID-19 statistics in Mexico report almost exclusively in-hospital mortality events, excess out-of-hospital mortality has been identified in other settings, including one EMS study in Italy that showed a 58% increase. EMS and hospital reports from several countries have suggested that silent hypoxemia--low oxygen saturation (SpO2) in the absence of dyspnea--is associated with COVID-19 outbreaks. It is unclear, however, how these phenomena can be generalized to LMICs. We assess how EMS data can be used in a sentinel capacity in Tijuana, a city on the Mexico-United States border with earlier exposure to COVID-19 than many LMIC settings. METHODS: We calculated numbers of weekly out-of-hospital deaths and respiratory cases seen by EMS in Tijuana, and estimate the difference between peak-epidemic rates (during April 14th-May 11th) and forecasted 2014-2019 trends. Results were compared with official COVID-19 statistics, stratified by neighborhood socioeconomic status (SES), and examined for changing demographic or clinical features, including mean (SpO2). RESULTS: An estimated 194.7 (95%CI: 135.5-253.9) excess out-of-hospital deaths events occurred, representing an increase of 145% (70%-338%) compared to forecasted trends. During the same window, only 8 COVID-19-positive, out-of-hospital deaths were reported in official statistics. This corresponded with a rise in respiratory cases of 274% (119%-1142%), and a drop in mean SpO2 to 77.7%, from 90.2% at baseline. The highest out-of-hospital death rates were observed in low-SES areas, although respiratory cases were more concentrated in high-SES areas. CONCLUSIONS: EMS systems may play an important sentinel role in monitoring excess out-of-hospital mortality and other trends during the COVID-19 crisis in LMICs. Using EMS data, we observed increases in out-of-hospital deaths in Tijuana that were nearly threefold greater magnitude than increases reported using EMS data in Italy. Increased testing in out-of-hospital settings may be required to determine if excess mortality is being driven by COVID-19 infection, health system saturation, or patient avoidance of healthcare. We also found evidence of worsening rates of hypoxemia among respiratory patients seen by EMS, suggesting a rise in silent hypoxemia, which should be met with increased detection and clinical management efforts. Finally, we observed that social disparities in out-of-hospital death that warrant monitoring and amelioration.

Changing Management Guidelines in Thyrotoxic Hypokalemic Periodic Paralysis.

BACKGROUND: Periodic paralysis is a rare complication of hyperthyroidism. Patients of East Asian descent are most commonly affected. Presentation is characterized by recurrent episodes of painless, abrupt-onset weakness, with laboratory evaluation characterized by profound hypokalemia. Underlying hyperthyroidism may not be clinically evident, but differentiation from the familial variant is critical due to differing treatment pathways. CASE REPORT: We describe the presentation of a 22-year-old man with recurrent relapsing-remitting weakness with undiagnosed hyperthyroidism. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients with acute-onset paralysis with significant hypokalemia, or relapsing-remitting symptoms, hyperthyroidism should be suspected. Obese patients are at an especially increased risk due to underlying insulin resistance, which enhances basal sodium-potassium ATPase function. Hypokalemia is functional in nature. Nonselective ß-blockers (such as propranolol) should be considered first line, as they simultaneously decrease ATPase activity, limit insulin secretion, and address the underlying disorder. Administration of > 50 mEq of exogenous potassium places patients at risk of dysrhythmias from rebound hyperkalemia.