Extremity Ischemia After Jellyfish Envenomation: A Case Report and Systematic Review of the Literature.

BACKGROUND: Extremity ischemia and necrosis after jellyfish envenomation can be mutilating and cause long-term functional deficits. The best way to manage these presentations is unknown. OBJECTIVE: The aim of this review was to establish an evidence-based consensus for the management of extremity ischemia after jellyfish envenomation. METHODS: A systematic review of cases of extremity ischemia and necrosis after envenomation by marine cnidarians was performed to clarify what is and what is not known about management and outcomes, to draw conclusions about how best to manage these rare presentations, and to establish an evidence-based algorithm. RESULTS: The ischemic sequelae of envenomation typically evolves over a few days. Close medical supervision is necessary to react promptly to the evolving clinical scenario. In the literature, 15 different pharmacologic classes have been used to manage these presentations. Only IV infusions of prostaglandin derivatives and intra-arterial thrombolytics have been found to improve the clinical picture and avoid the need for surgical fasciotomy and debridement in some cases. Anticoagulants, antiplatelet agents, steroids, antibiotics, and nitrates, which are among the most commonly prescribed pharmacologic agents, have not been observed to alter the clinical picture. CONCLUSIONS: Surgery for compartment syndrome and necrosis are common sequelae of extremity envenomation by marine cnidarians. Only prompt use of IV prostaglandins or intra-arterial thrombolytics can halt ischemic progression and avoid the need for surgery. An algorithm is proposed to guide management of these rare and mutilative presentations.

Poor Agreement but Good Predictive Value Between Automated and Manual QTc Intervals in Pediatric Emergency Department Electrocardiograms.

OBJECTIVES: QTc interval is significant because prolongation may lead to ventricular dysrhythmia. Computerized electrocardiogram machines typically measure QT interval length and, using an algorithm assessment of multiple leads, calculate a QTc value. Manual measurement of the QT interval used to calculate the QTc value is more time-consuming but potentially more accurate. In this study, we compare the automated QTc calculation with the QTc value calculated using manual QT measurements. METHODS: We prospectively obtained 350 resting 12-lead electrocardiograms (ECGs) in children aged 2 to 14 years in an academic pediatric emergency department. Manual measurement of the QT interval was performed and the QTc was calculated using the 2 most commonly used correction methods, Bazzet and Fridericia formulas. The paired values were used to perform a Bland-Altman analysis and create a receiver operating characteristic curve. RESULTS: Bland-Altman analysis determined that QT-automated and QTc-Bazett had an average difference of 3.8 milliseconds, with a standard deviation of 86 milliseconds (95% confidence interval = -161 to 176). An automated QTc value of 455 milliseconds was sensitive to detect manual QTc values of greater than 480 milliseconds. CONCLUSIONS: In children with resting ECGs, there is a poor agreement between the automated QTc produced by a computerized electrocardiogram and the QTc value obtained using manual QT measurement. Statistically and clinically relevant discrepancy between the automated QTc and QTc values calculated after manual QT measurement was present. Automated QTc values may be used as a screening tool to detect prolonged QTc, but for accurate determination of QTc, manual measurement is necessary.

Earlier Hospital Discharge With Prospectively Designated Discharge Time in the Electronic Health Record.

BACKGROUND AND OBJECTIVES: Hospital discharge requires multidisciplinary coordination. Insufficient coordination impacts patient flow, resource use, and postdischarge outcomes. Our objectives were to (1) implement a prospective, multidisciplinary discharge timing designation in the electronic health record (EHR) and (2) evaluate its association with discharge timing. METHODS: This quality-improvement study evaluated the implementation of confirmed discharge time (CDT), an EHR designation representing specific discharge timing developed jointly by a patient's family and the health care team. CDT was intended to support task management and coordination of multidisciplinary discharge processes and could be entered and viewed by all team members. Four plan-do-study-act improvement phases were studied: (1) baseline, (2) provider education, (3) provider feedback, and (4) EHR modification. Statistical process control charts tracked CDT use and the proportion of discharges before noon. Length of stay was used as a balancing measure. RESULTS: During the study period from April 2013 through March 2017, 20 133 pediatric discharges occurred, with similar demographics observed throughout all phases. Mean CDT use increased from 0% to 62%, with special cause variations being detected after the provider education and EHR modification phases. Over the course of the study, the proportion of discharges before noon increased by 6.2 percentage points, from 19.9% to 26.1%, whereas length of stay decreased from 47 (interquartile range: 25-95) to 43 (interquartile range: 24-88) hours (both P < .001). CONCLUSIONS: The implementation of a prospective, multidisciplinary EHR discharge time designation was associated with more before-noon discharges. Next steps include replicating results in other settings and determining populations that are most responsive to discharge coordination efforts.

Confluent Retropharyngeal, Lateral Pharyngeal, and Peritonsilar MRSA Abscess in an Infant.

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. The causative organism was methicillin-resistant Staphylococcus aureus.

A case of syphilitic hepatitis in an HIV-infected patient.

While the incidence of syphilis has been persistently on the rise in the United States, hepatitis as a complication of early syphilis is relatively uncommon. We present a case of a 51-year-old homosexual, HIV-positive man who presented with acute cholestatic hepatitis with a predominantly elevated alkaline phosphatase. After laboratory studies and imaging were unrevealing, a liver biopsy was performed that showed expanded portal tracts with a predominantly lymphoplasmacytic infiltrate and prominent bile ductular proliferation with periductal neutrophils. Testing revealed a positive rapid plasma reagin, and a subsequent Warthin-Starry stain of the liver tissue demonstrated the presence of scattered spirochetes, confirmed as Treponema pallidum spirochetes on immunohistochemistry testing. These findings confirmed a diagnosis of syphilitic hepatitis. With therapy, symptoms and liver enzymes rapidly normalized. Given the persistent rise in syphilis incidence along with the morbidity and mortality associated with a missed diagnosis, keen suspicion, early identification, and treatment are crucial.

Effect of intravenous ondansetron on QTc interval in children with gastroenteritis.

BACKGROUND: The potential for ondansetron to cause QT prolongation and fatal dysrhythmia is well-reported, including a 2011 FDA report on the topic. Few clinical trials evaluating this phenomenon in the ED setting exist, and only one is pediatric. OBJECTIVE: We have sought to determine the effect of a standardized dose of intravenous ondansetron on the QTc duration of children under 14years of age treated for gastroenteritis-associated vomiting in a pediatric ED. This study is modeled closely after an FDA "thorough QT study". METHODS: EGCs were obtained before and 15, 30, 45, and 60min after a 0.15mg/kg IV dose of ondansetron given for gastroenteritis-associated vomiting. QT intervals were measured manually with digital calipers, and the QTc interval calculated both by Bazett's (QTcB) and Fridericia's (QTcF) correction. A paired t-test comparing QTc was conducted, and frequency of categorical outcomes of prolongation>30msec, >60 msec, and absolute prolongation >450 msec, >480 msec, and >500msec were evaluated. RESULTS: In a 4-month period, 134 patients were included in the study, 46% were male. The average QTc prior to ondansetron administration was: QTcB 415 msec (95% CI 343-565) and QTcF 373 (95% CI 304-499). The mean difference in QTc after ondansetron was 0.4msec for QTcB (95% CI -35-45msec) and 0.1msec for QTcF (95% CI -40-18msec). CONCLUSION: In these children, 0.15mg/kg of intravenous ondansetron did not cause prolongation of QTcB or QTcF measured 15min after administration, nor at later times.

Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections.

BACKGROUND: Urinary tract infections (UTI) are the most common type of infection in the United States. A Centers for Disease Control and Prevention report in March 2014 regarding antibiotic use in hospitals reported "UTI" treatment was avoidable at least 39% of the time. The accurate diagnosis and treatment of UTI plays an important role in cost-effective medical care and appropriate antimicrobial utilization. OBJECTIVE: We summarize the most common misperceptions of UTI that result in extraneous testing and excessive antimicrobial treatment. We present 10 myths associated with the diagnosis and treatment of UTI and succinctly review the literature pertaining to each myth. We explore the myths associated with pyuria, asymptomatic bacteriuria, candiduria, and the elderly and catheterized patients. We attempt to give guidance for clinicians facing these clinical scenarios. DISCUSSION: From our ambulatory, emergency department, and hospital experiences, patients often have urine cultures ordered without an appropriate indication, or receive unnecessary antibiotic therapy due to over-interpretation of the urinalysis. CONCLUSIONS: Asymptomatic bacteriuria is common in all age groups and is frequently over-treated. A UTI diagnosis should be based on a combination of clinical symptoms with supportive laboratory information. This review will assist providers in navigating common pitfalls in the diagnosis of UTI.

Femur Fracture Diagnosis and Management Aided by Point-of-Care Ultrasonography.

We describe a point-of-care ultrasonography to facilitate diagnosis of a femur fracture in a 13-year-old adolescent boy. Rapid detection of the fracture, which was not possible by physical examination alone, permitted immediate stabilization of the leg with traction, rapid communication with orthopedic surgeons, and facilitated analgesic therapy before transport and movement to obtain radiographs.

Comparison of temporal artery thermometry and rectal thermometry in febrile pediatric emergency department patients.

OBJECTIVES: Fever is among the most common reasons for emergency department (ED) visits by children. This study compares temporal artery thermometry to rectal thermometry in febrile children in an ED. METHODS: This was a retrospective evaluation of children younger than 36 months treated consecutively in an urban medical center. Patients underwent triage with temporal artery thermometry, and after transfer to the pediatric ED, they underwent rectal thermometry. Fever was defined as rectal temperature of 100.4 °F (38 °C) or greater, and 147 patients met this definition. Data extraction from electronic charts obtained paired temporal artery and rectal temperatures, and these were compared by Bland-Altman analysis. Temperature points of 100.4 °F (38 °C) and 102.2 °F (39 °C) were evaluated to compare temporal artery thermometry with rectal thermometry sensitivity and specificity. RESULTS: A statistically and clinically significant difference between temporal artery and rectal temperature was found. Temporal artery thermometry was 53% sensitive detecting rectal temperature 100.4 °F (38 °C) or greater, and 27% sensitive detecting rectal temperature of 102.2 °F (39 °C) or greater. Mean rectal temperature was 102.36 °F (39.09 °C) (95% confidence interval [CI], 102.14 °F-102.58 °F); mean temporal artery temperature was 100.36°F (37.98 °C) (95% CI, 100.08 °F-100.65 °F), and mean difference between the two was 1.99 °F (1.11 °C) (95% CI, 1.75 °F-2.23 °F). CONCLUSIONS: Temporal artery thermometry is poorly sensitive detecting fever and does not accurately reflect rectal temperature. Temporal artery thermometry should not be used for clinical management of children younger than 36 months if detection of fever is of importance.

Clinical confounder: an incarcerated appendix masquerading as epididymitis.

BACKGROUND: Acute appendicitis can have various unusual presentations. Detection of this entity is often confounded by its presence in the company of symptoms consistent with distinctly different etiologies. OBJECTIVES: This article highlights an extremely rare presentation of appendicitis. CASE REPORT: The case of a man presenting to an urban Emergency Department complaining of scrotal swelling and pain is discussed. On surgical exploration, the patient's symptomatology was diagnosed as acute appendicitis within an Amyand hernia. CONCLUSION: Appendicitis can sometimes be a challenging diagnosis. Thorough examination and maintenance of a wide differential diagnosis with common complaints can assist the emergency physician in reaching the correct diagnosis.

Toxin-related seizures.

Toxin-related seizures result from an imbalance in the brain's equilibrium of excitation-inhibition. Fortunately, most toxin-related seizures respond to standard therapy using benzodiazepines. However, a few alterations in the standard approach are recommended to ensure optimal care and expedient termination of seizure activity. If 2 doses of a benzodiazepine do not terminate the seizure activity, a therapeutic dose of pyridoxine (5 g intravenously in an adult and 70 mg/kg intravenously in a child) should be considered. Phenytoin should be avoided because it is ineffective for many toxin-induced seizures and is potentially harmful when used to treat seizures induced by theophylline or cyclic antidepressants.

Ethics, equipoise, and evidence: when should investigators decide to not test their hypothesis.

In an excellent investigation of endotracheal tube cuff pressure assessment, "Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport," Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits. Although a study of this type has not been conducted on patients who are endotracheally intubated by emergency medicine physicians within the confines of an emergency department, we pose the question to the academic and clinical emergency medicine community, "Should such a study be conducted?" Instead, should the evidence offered by Chapman et al, in addition to that of other publications, be enough to prompt emergency physicians to abandon the practice of endotracheal intubation without measurement and/or control of endotracheal tube cuff pressure? To adequately understand the complexity of such an apparently simple question, it is necessary to consider 2 concepts: equipoise and evidence. Our hope is that readers will acknowledge the study of Chapman et al as a strong piece of evidence indicating that patients who undergo endotracheal intubation without measurement of endotracheal tube cuff pressure very likely have a pressure that exceeds the safe range. We hope this study, in conjunction with the other available evidence, will prompt readers to adopt measurement of endotracheal tube cuff pressure as a routine.

Linear correlation of endotracheal tube cuff pressure and volume.

OBJECTIVES: Endotracheal tube cuff (ETTc) inflation by standard methods may result in excessive ETTc pressure. Previous studies have indicated that methods of cuff inflation most frequently used to inflate ETTcs include palpation of the tension in the pilot balloon or injection of a predetermined volume of air to inflate the pilot balloon. If a logarithmic relationship exists between ETTc volume and ETTc pressure, small volumes of additional air will result in dramatic pressure increases after a volume threshold is reached. Our goal was to determine whether the relationship between ETTc volume and ETTc pressure is linear or non-linear. METHODS: In this Institutional Animal Care and Use Committee-approved study, we recorded ETTc volume and pressure in four anesthetized and mechanically-ventilated canines ranging between 30-40 pounds (mean 34.7lb, SD 3.8lb) that were endotracheally intubated with a 7.0 mm ETT. The varying cuff pressures associated with a distribution of 28 progressively increasing volumes of air in the ETTc were recorded. Spearman correlation was performed to determine if a linear or non-linear relationship existed between these variables. RESULTS: The Spearman rho coefficient of correlation between ETTc volume and ETTc pressure was 0.969, or approximately 97%, suggesting near-perfect linear relationship between ETTc volume and ETTc pressure over the range of volumes and pressures tested. CONCLUSIONS: Over the range of volumes and pressures tested a linear relationship between volume and pressure results in no precipitous increase in slope of the pressure:volume curve as volume increases.

In vitro-activated charcoal binding of staphylococcal enterotoxin B.

OBJECTIVE: Staphylococcal enterotoxin B (SEB) is a CDC category B bioterror agent that may cause significant morbidity. We assessed the in vitro binding of SEB by activated charcoal (AC). METHODS: Aqueous solutions of SEB at three concentrations (0.4, 2 and 10 mcg/mL) were combined in volume rations of 3:1, 6:1, and 12:1 with AC at three concentrations (62.5, 125, and 250 mg/mL) or left untreated as control samples. Subsequently, each sample was tested with a qualitative SEB immunoassay to detect the presence of SEB at concentrations of >12.5 ng/mL. RESULTS: SEB was detectable in each untreated control solution. SEB was undetectable in the 2 mcg/mL and 0.4 mcg/mL solutions after treatment with AC in all quantities. SEB was detected in the 10 mcg/mL solution after combination with all three concentrations of AC. The difference in assay results between charcoal treated and untreated pairs was statistically significant. CONCLUSION: At ratios of 3:1 and above, SEB was adsorbed by AC when combined in the manner described in concentrations of 2 mcg/mL and 0.4 mg/mL. In a quantity of 10 mcg/mL complete charcoal binding of SEB did not occur with any ratio of AC used. These results support a role for AC in treating patients exposed to SEB or purifying liquids or gases containing SEB.

Practicing paramedics cannot generate or estimate safe endotracheal tube cuff pressure using standard techniques.

OBJECTIVES: We sought to determine the ability of paramedics to inflate endotracheal tube cuffs within safe pressure limits as well as to estimate the pressure of previously inflated endotracheal tube cuffs by palpation of the pilot balloon. METHODS: Using a tracheal simulation model, we conducted a prospective, observational, cross-sectional simulation study of licensed, practicing paramedics. This included evaluation of their ability to inflate the cuff of an endotracheal tube to a safe pressure, defined as < or = 25 cm H(2)O, as well as to identify excessive intracuff pressure in previously inflated ETT cuffs by palpation of the pilot balloon. RESULTS: Fifty-three paramedics were sampled. The average pressure generated by inflating the endotracheal tube cuff was > 108 cm H(2)O. Participants were only 13% sensitive detecting over inflated endotracheal tube cuffs (95% CI 7.3-17.8). CONCLUSIONS: Participants were unable to inflate endotracheal tube cuff to safe pressures and were unable to identify endotracheal tube cuffs with excessive intracuff pressure by palpation. Clinicians should consider using devices such as manometers to facilitate safe inflation and accurate measurement of endotracheal tube cuff pressure.

Experienced emergency medicine physicians cannot safely inflate or estimate endotracheal tube cuff pressure using standard techniques.

OBJECTIVE: Tracheal necrosis, stenosis, and rupture may result from overinflated endotracheal tube cuffs (ETTcs). We sought to determine the ability of faculty emergency medicine (EM) physicians to safely inflate ETTc as well as to estimate pressure of previously inflated ETTc. METHODS: Using a previously tested tracheal simulation model, we assessed EM physician inflation of ETTc pilot balloons. Participants also palpated the pilot balloon of 9 ETTc inflated to pressures ranging from extremely low to extremely high in a random order and reported their estimate of pressure. RESULTS: We sampled 41 faculty EM physicians from 5 EM residency programs. Using palpation, participants were only 22% sensitive detecting overinflated ETTc. The average ETTc pressure produced by inflation was more than 93 cm H(2)O (normal, 15-25 cm H(2)O). CONCLUSIONS: Participants were unable to inflate ETTc to safe pressures or estimate pressure of ETTc by palpation. Clinicians should consider using devices to facilitate safe inflation and accurate measurement of ETTc pressure.