Ultrasound-Guided Erector Spinae Plane Block: A Case Series Demonstrating Utility for Acutely Painful Conditions in the Emergency Setting.

Ultrasound-guided erector spinae plane block (ESPB) has emerged as a valuable technique in pain management. Though frequently used in chronic and postoperative pain, it remains underutilized in the emergency department (ED) setting. In particular, this block has become attractive because it is rapid, safe, and efficacious for a variety of different pain syndromes that are commonly encountered in the emergency department setting. Of particular importance is that this block results in pure sensory blockade, allowing patient movement after the procedure has been performed. This case series explores the efficacy of the ESPB in various clinical scenarios, including refractory cervical radiculopathy, rib fractures, obstructive nephrolithiasis, and sciatica. Each of these patients presented with symptoms of refractory aggressive pain management strategies, including non-steroidal anti-inflammatory drugs (NSAIDS), acetaminophen, narcotics, muscle relaxers, and ketamine. After undergoing ESPB, the patients were able to be successfully discharged without return visits to the emergency department for the return of their pain. This case series aims to show the utility of this procedure for refractory painful conditions and also reviews other indications where the block may be used. While previous reports have shown the utility of this block at individual levels, we present the flexibility of this block being used at multiple levels of the spine.

Atraumatic Vertebral Artery Dissection in a Patient With a Migraine Headache.

This case discusses a 34-year-old active duty male who presented to the emergency department with a 2-week persistent headache. His initial review of symptoms was reassuring until a detailed neurologic examination on his second visit revealed a visual deficit in the left upper quadrant. Additionally, he complained of intermittent tension headaches for the last several years but had no history of diagnosed migraines until he was seen 4 days prior for empiric migraine therapy in the same emergency department and left without improvement in symptoms. On his return visit, computerized tomography scan with intravenous contrast revealed a left vertebral artery dissection and hematoma. The patient was admitted for medical management and subsequently found to have suffered a small infarction of right lingual gyrus cortex on magnetic resonance imaging. This case illustrates the importance of maintaining a broad differential diagnosis and high index of suspicion in the patient with new focal neurologic findings in order to diagnose a potentially fatal disease.

Rapid outdoor non-compression intubation (RONCI) of cardiac arrests to mitigate COVID-19 exposure to emergency department staff.

The COVID-19 pandemic has introduced numerous challenges for Health Care Professionals, including exposing Emergency Department (ED) staff to the SARS-CoV-2 virus during Cardiopulmonary Resuscitation (CPR). Recent guidelines from the American Heart Association (AHA) prioritize early intubation with viral filter placement to minimize hospital staff exposure. We propose a novel technique for rapid outdoor non-compression intubation (RONCI) of cardiac arrest patients while en route from the ambulance bay to the resuscitation bay to further decrease the risk of viral aerosolization.

Penetrating Vascular Injury: Diagnosis and Management Updates.

Penetrating vascular injury is becoming increasingly common in the United States and abroad. Much of the current research and treatment is derived from wartime and translation to the civilian sector has been lacking. Penetrating vascular injury can be classified as extremity, junctional, or noncompressible. Diagnosis can be obvious but at other times subtle and difficult to diagnose. Although there are numerous modalities, computed tomography angiography is the diagnostic study of choice. It is hoped that care will be improved by using an algorithmic approach integrating experience from military and civilian research.

The emergency medicine approach to abdominal vascular graft complications.

INTRODUCTION: Abdominal aortic aneurysm (AAA) is a deadly condition, particularly with rupture. Emergency physicians provide vital frontline care to the diagnosis and treatment of this disease. Endovascular aortic repair (EVAR) has become the gold standard for treatment of AAA, but the management of EVAR complications is not well discussed in the emergency medicine literature. OBJECTIVE OF THIS REVIEW: The purpose of this article is to provide an emergency medicine-focused review of the complications of EVAR. DISCUSSION: Although many complications may arise after AAA repair, the most common include aortoenteric fistula, endoleak, limb ischemia, and graft infection. All potential complications should receive vascular surgery consultation and hemodynamic resuscitation. Aortoenteric fistula often presents nonspecifically with gastrointestinal (GI) bleeding, abdominal pain, and vomiting. Computed tomography with intravenous contrast is required for diagnosis. An endoleak is defined by vascular flow outside of the graft. The optimal diagnostic modality includes triple phase computed tomographic scan (noncontrast, arterial, delayed phase). Limb ischemia may occur before 2 months, or in a later period, with symptoms ranging from claudication to complete neurovascular compromise. Graft infection is most commonly due to Staphylococcus aureus, and imaging can suggest the diagnosis. Definitive diagnosis requires tissue or fluid sampling. Through an understanding of these complications, emergency physicians may improve patient outcomes. CONCLUSIONS: With the growing use of EVAR, emergency physician exposure to complications of this procedure is increasing. Knowledge of the complication presentations, diagnoses, and management can play an integral role patient care.

Uterine Incarceration: Rare Cause of Urinary Retention in Healthy Pregnant Patients.

Gravid uterine incarceration (GUI) is a condition that is well discussed in literature; however, there are few acute diagnoses in the emergency department (ED). We present a case series where three multiparous females presented to the ED with non-specific urinary symptoms. On bedside ultrasound, each patient was noted to have a retroverted uterus and inferior bladder entrapment under the sacral promontory. GUI is a rare condition that can lead to uremia, sepsis, peritonitis, and ultimately maternal death. Emergency physicians should include GUI in their differential diagnosis in this patient population and use bedside ultrasound as an adjunct to diagnosis.

IT-141, a Polymer Micelle Encapsulating SN-38, Induces Tumor Regression in Multiple Colorectal Cancer Models.

Polymer micelles are promising drug delivery vehicles for the delivery of anticancer agents to tumors. Often, anticancer drugs display potent cytotoxic effects towards cancer cells but are too hydrophobic to be administered in the clinic as a free drug. To address this problem, a polymer micelle was designed using a triblock copolymer (ITP-101) that enables hydrophobic drugs to be encapsulated. An SN-38 encapsulated micelle, IT-141, was prepared that exhibited potent in vitro cytotoxicity against a wide array of cancer cell lines. In a mouse model, pharmacokinetic analysis revealed that IT-141 had a much longer circulation time, plasma exposure, and tumor exposure compared to irinotecan. IT-141 was also superior to irinotecan in terms of antitumor activity, exhibiting greater tumor inhibition in HT-29 and HCT116 colorectal cancer xenograft models at half the dose of irinotecan. The antitumor effect of IT-141 was dose-dependent and caused complete growth inhibition and tumor regression at well-tolerated doses. Varying the specific concentration of SN-38 within the IT-141 micelle had no detectible effect on this antitumor activity, indicating no differences in activity between different IT-141 formulations. In summary, IT-141 is a potent micelle-based chemotherapy that holds promise for the treatment of colorectal cancer.