Acute Obstructive Hydrocephalus: An Unexpected Cause of Cardiac Arrest.

BACKGROUND: Emergency physicians are well-versed in managing cardiac arrests, including the diagnostic and therapeutic steps after return of spontaneous circulation. Neurologic emergencies are a common cause of out-of-hospital cardiac arrest and must remain high in the differential diagnosis, as such cases often require specific interventions that may deviate from more common care pathways. Performing a noncontrast head computed tomography (NCHCT) scan after cardiac arrest has been found to change management, although the optimal timing of this imaging is unclear. CASE REPORT: This is the case of a young, pregnant woman who presented to the emergency department after cardiac arrest with return of spontaneous circulation in the prehospital setting. She was found to have acute obstructive hydrocephalus on NCHCT, which was later confirmed to be due to a previously undiagnosed colloid cyst of the third ventricle. This acute obstruction resulted in myocardial stunning and, ultimately, cardiac arrest. Although outcomes are often dismal when the cause of arrest is secondary to neurologic catastrophe, this patient survived with completely intact neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although acute obstructive hydrocephalus due to a colloid cyst adjacent to the third ventricle is a rare condition, it is a potentially reversible neurologic cause of out-of-hospital cardiac arrest. However, positive outcomes depend on obtaining the diagnosis rapidly with neurologic imaging and advocating for neurosurgical intervention. This case supports the recommendation that emergency physicians should strongly consider post-cardiac arrest neurologic imaging when another cause is not immediately obvious.

A taxonomy of key performance errors for emergency intubation.

STUDY OBJECTIVE: Currently the videographic review of emergency intubations is an unstructured, qualitative process. We created a taxonomy of errors that impede the optimal procedural performance of emergency intubation. METHODS: This was a prospective, observational, study reviewing a convenience sample of deidentified laryngoscopy recordings of emergency department intubations that were qualitatively flagged before the study as demonstrating suboptimal technique. These videos were coded for the presence of 13 predetermined performance errors. Our primary outcome was the incidence of each of these specified errors during emergency intubation. Errors fell into 3 categories: errors of structure recognition during laryngoscope insertion, errors of vallecula manipulation, and errors of device delivery. RESULTS: A total of 100 intubation attempts were reviewed. The most common error was inadequate lifting force with the blade tip in the vallecula which lowered the percent of glottic opening, occurring in 45% of the attempts. The least common performance error was the premature removal of the laryngoscope during bougie placement, occurring in only 9% of the videos. CONCLUSION: We developed a taxonomy of 13 performance errors of laryngoscopy. Further study is warranted to determine how to best incorporate these into emergency airway training and the airway review process.

FOCUS may detect wall motion abnormalities in patients with ACS.

BACKGROUND: Chest pain is a common presentation to the Emergency Department (ED) with roughly 6 million visits a year. The primary diagnostic modality for the identification of acute coronary syndrome (ACS) is the electrocardiogram (ECG), which is used to screen for electrocardiographic findings representing acute coronary occlusion. It is known that the ischemia generated by an acutely occluded coronary vessel generates a wall motion abnormality which can be visualized by echocardiogram; however, emergency physician-performed focused cardiac ultrasound (FOCUS) currently does not have a formal role in the diagnosis of OMI within the emergency department. PURPOSE: We sought to define the characteristics of FOCUS performed by emergency physicians of variable training levels in the identification of RWMA in patients presenting to the emergency department with high suspicion for ACS before undergoing cardiac catheterization or formal echocardiography. We also explored whether RWMA was associated with OMI in these patients. METHODS: We performed a structured, retrospective review of adult patients presenting to a large, academic, tertiary care center with suspected ACS from July 1st, 2019, and October 24th, 2020. Patients were included if they underwent FOCUS in the ED during the time-period above for suspected ACS looking for RWMA and FOCUS images were stored and reviewable in our middleware software. The primary outcome was the accuracy, sensitivity, and specificity of FOCUS compared to formal echocardiography for the detection of RWMA. Secondary outcomes were sensitivity of FOCUS compared to formal echocardiography for detection of RWMA in patients with and without cardiac catheterization proven OMI and sensitivity and specificity of FOCUS operators based on training. RESULTS: FOCUS for RWMA performed by emergency physicians had a sensitivity of 94% (95% CI, 82-98), specificity 35% (95% CI, 15-61), and overall accuracy of 78% (95% CI, 66-87). Of all subjects, 82% underwent urgent or emergency coronary angiography, of which 71% had OMI at the time of coronary angiography of the procedure. FOCUS identified RWMA in 87% of patients with coronary angiography proven OMI. Residents (PGY-1 - PGY-3) (n = 31) were able to detect RWMA with a sensitivity of 86% (95% CI, 64-96), a specificity of 56% (95% CI, 23-85%), and an accuracy of 77 (95% CI, 58-90%). Emergency ultrasound fellows and attendings (n = 34) were able to detect RWMA with a sensitivity of 85% (95% CI, 64-95%), a specificity of 75% (95% CI, 36-96%), and an accuracy of 82% (95% CI, 65-93%). CONCLUSIONS: Our retrospective study concludes FOCUS performed by emergency physicians may be used to detect RWMA in patients with high concern for acute coronary syndrome. This may have its greatest utility in patients presenting without STEMI where the ECG is felt to be equivocal, but the clinician has high concern for OMI, in which the presence of RWMA might result in emergent cath lab activation, though this requires further study. The presence of RWMA in such cases may help to rule in OMI as a cause; however, the absence of RWMA should exclude OMI. Further research is necessary to confirm these findings.

Post-arrest wide complex rhythm: What is the cause of death?

A 72-year-old man presented to the ED following witnessed cardiac arrest. After return of spontaneous circulation, an ECG was performed which demonstrated a wide complex rhythm with "shark fin" morphology. With careful examination it is possible to identify the J point and determine that the electrocardiogram (ECG) findings actually represent massive ST-elevation indicative of occlusion myocardial infarction (OMI). Initial troponin was undetectable. The patient underwent emergent cardiac catheterization and had a 100% proximal LAD occlusion that was successfully stented. The patient was discharged home neurologically intact several days later. This case highlights the importance of careful ECG interpretation and the limitations of troponin assays in the evaluation of acute coronary syndrome. Most importantly, we demonstrate how to evaluate for ST elevation in the context of a widened QRS complex.

Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI.

BACKGROUND: The current ST-elevation myocardial infarction (STEMI) vs. non-STEMI (NSTEMI) paradigm prevents some NSTEMI patients with acute coronary occlusion from receiving emergent reperfusion, in spite of their known increased mortality compared with NSTEMI without occlusion. We have proposed a new paradigm known as occlusion MI vs. nonocclusion MI (OMI vs. NOMI). OBJECTIVE: We aimed to compare the two paradigms within a single population. We hypothesized that STEMI(-) OMI would have characteristics similar to STEMI(+) OMI but longer time to catheterization. METHODS: We performed a retrospective review of a prospectively collected acute coronary syndrome population. OMI was defined as an acute culprit and either TIMI 0-2 flow or TIMI 3 flow plus peak troponin T > 1.0 ng/mL. We collected electrocardiograms, demographic characteristics, laboratory results, angiographic data, and outcomes. RESULTS: Among 467 patients, there were 108 OMIs, with only 60% (67 of 108) meeting STEMI criteria. Median peak troponin T for the STEMI(+) OMI, STEMI(-) OMI, and no occlusion groups were 3.78 (interquartile range [IQR] 2.18-7.63), 1.87 (IQR 1.12-5.48), and 0.00 (IQR 0.00-0.08). Median time from arrival to catheterization was 41 min (IQR 23-86 min) for STEMI(+) OMI compared with 437 min (IQR 85-1590 min) for STEMI(-) OMI (p < 0.001). STEMI(+) OMI was more likely than STEMI(-) OMI to undergo catheterization within 90 min (76% vs. 28%; p < 0.001). CONCLUSIONS: STEMI(-) OMI patients had significant delays to catheterization but adverse outcomes more similar to STEMI(+) OMI than those with no occlusion. These data support the OMI/NOMI paradigm and the importance of further research into emergent reperfusion for STEMI(-) OMI.

Prioritising intubator safety in a pandemic: the details matter.

Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.

Early Identification of Takotsubo syndrome in the emergency department using point-of-care echocardiography: A case series.

Takotsubo syndrome (TS) is an incompletely understood, transient dysfunction of the left ventricle. While acute coronary syndrome must be at the forefront of the differential diagnosis and ruled out appropriately, the possibility of TS can be identified early with point-of-care ultrasonography. The formal diagnostic criteria for TS rely on invasive diagnostic procedures and resolution of symptoms, typically relegating it to a diagnosis of exclusion. However, the acute complications are potentially lethal, and rapid identification is therefore beneficial because these patients can be risk-stratified to higher levels of care. Our case series of three patients, each with early suspected and subsequently confirmed TS, explores how early emergency department ultrasonography can suggest the diagnosis during the emergent workup, and potentially influence disposition decisions, subsequent interventions, and possibly even outcomes.

Cohort of Four Thousand Four Hundred Four Persons Under Investigation for COVID-19 in a New York Hospital and Predictors of ICU Care and Ventilation.

Study objective: Most coronavirus disease 2019 (COVID-19) reports have focused on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients. However, at initial presentation, most patients' viral status is unknown. Determination of factors that predict initial and subsequent need for ICU and invasive mechanical ventilation is critical for resource planning and allocation. We describe our experience with 4,404 persons under investigation and explore predictors of ICU care and invasive mechanical ventilation at a New York COVID-19 epicenter. Methods: We conducted a retrospective cohort study of all persons under investigation and presenting to a large academic medical center emergency department (ED) in New York State with symptoms suggestive of COVID-19. The association between patient predictor variables and SARS-CoV-2 status, ICU admission, invasive mechanical ventilation, and mortality was explored with univariate and multivariate analyses. Results: Between March 12 and April 14, 2020, we treated 4,404 persons under investigation for COVID-19 infection, of whom 68% were discharged home, 29% were admitted to a regular floor, and 3% to an ICU. One thousand six hundred fifty-one of 3,369 patients tested have had SARS-CoV-2-positive results to date. Of patients with regular floor admissions, 13% were subsequently upgraded to the ICU after a median of 62 hours (interquartile range 28 to 106 hours). Fifty patients required invasive mechanical ventilation in the ED, 4 required out-of-hospital invasive mechanical ventilation, and another 167 subsequently required invasive mechanical ventilation in a median of 60 hours (interquartile range 26 to 99) hours after admission. Testing positive for SARS-CoV-2 and lower oxygen saturations were associated with need for ICU and invasive mechanical ventilation, and with death. High respiratory rates were associated with the need for ICU care. Conclusion: Persons under investigation for COVID-19 infection contribute significantly to the health care burden beyond those ruling in for SARS-CoV-2. For every 100 admitted persons under investigation, 9 will require ICU stay, invasive mechanical ventilation, or both on arrival and another 12 within 2 to 3 days of hospital admission, especially persons under investigation with lower oxygen saturations and positive SARS-CoV-2 swab results. This information should help hospitals manage the pandemic efficiently.

Association of Pain Location With Computed Tomography Abnormalities in Emergeny Department Patients With Abdominal Pain.

BACKGROUND: Over the last decade the usage of computed tomography (CT) imaging has risen dramatically in emergency department (ED) patients with abdominal pain. Recognizing the potential disadvantages of overuse of CT imaging, efforts are being made to reduce imaging. OBJECTIVE: We determined the operating characteristics for location of abdominal pain for the entities of acute appendicitis, diverticulitis, and intestinal obstruction. We hypothesized that patients with pain localized to the upper abdomen would be less likely to have CT abnormalities than those with lower abdominal pain. METHODS: This is a prospective, observational registry of ED patients with abdominal pain, performed in an academic, suburban ED with an annual census of 110,000. Presence of clinically significant CT abnormalities (e.g., appendicitis, diverticulitis, bowel obstruction) were recorded along with clinical variables including laboratory values, vital signs, reported location of pain, location of tenderness on examination, and physician pretest probability. RESULTS: A convenience sample of 1154 patients was enrolled. Of all patients, 273 cases (24%) had abnormal CT results, including appendicitis (n = 95), diverticulitis (n = 133), and bowel obstruction (n = 49). Right upper quadrant pain was negatively associated with abnormal CT (p = 0.02). Clinician gestalt was highly specific, but lacked sensitivity for the diagnosis of appendicitis, diverticulitis, and obstruction. Twenty-four percent of patients diagnosed with appendicitis had no right lower quadrant pain or tenderness, and 7% of patients with diverticulitis had no left lower quadrant pain or tenderness. CONCLUSIONS: Localization of abdominal pain by history or physical examination is not sufficient to accurately diagnose intra-abdominal pathology, especially cases of acute appendicitis, diverticulitis, or intestinal obstruction.

Man Presenting After Hydrochloric Acid Ingestion.

Case Presentation: We describe a case of a man who developed severe caustic injury of his upper gastrointestinal tract after ingestion of a commercially available 9.5% hydrochloric acidic cleaning solution. He rapidly deteriorated and required endotracheal intubation. He underwent several imaging modalities demonstrating his injuries and ultimately succumbed to his injuries. Discussion: Acidic caustic ingestions may range in severity and uncommonly result in death. Diagnosis is most often achieved by esophagogastroduodenoscopy, although computed tomography may increasingly play a role in defining the extent of injury. Esophagogastroduodenoscopy findings are often assigned a Zargar grade, which guides management. Medical management of acidic caustic ingestion may include bowel rest, steroids, antibiotics, and proton pump inhibitors depending on the extent of injury, although surgery may be required if esophageal perforation occurs.

Blueprint for the development of resuscitation and emergency critical care fellowships.

The volume of critically ill patients presenting to the emergency department (ED) is increasing rapidly. Continued growth will likely further stress an already strained U.S. health care system. Numerous studies have demonstrated an association with worsened outcomes for critically ill patients boarding in the ED. To address the increasing volume and complexity of critically ill patients presenting to EDs nationwide, resuscitation and emergency critical care (RECC) fellowships were developed. RECC programs teach a general approach to the management of the undifferentiated critically ill patient, advanced management of critically ill patients by disease presentation, and ongoing supportive care of the critically ill patient boarding in the ED. The result is critical care training beyond that of a typical emergency medicine (EM) residency with a focus on the unique features and challenges of caring for critically ill patients in the ED not normally found in critical care fellowships. Graduates from RECC fellowships are well suited to practicing in any ED practice model and may be especially well prepared for EDs that distinguish acuity between zones (e.g., resuscitative care units, ED-based intensive care units). In addition to further developing clinical acumen, RECC fellowships provide graduates with a niche in EM education, research, and administration. In this article, we describe the philosophical principles and practical components necessary for the creation of future RECC fellowships.

Bizarre T Waves: What Do They Mean?

Electrocardiographic artifacts are common and may often interfere with interpretation. We describe a case of bizarre appearing T waves. The left arm electrode was placed near a pulsatile fistula, which created an artery pulse tapping artifact. When encountering unexpected electrocardiographic findings, inspection of the electrocardiogram and lead placement may identify the cause. (Level of Difficulty: Intermediate.).

Rare but Foreseeable: Rapidly Expanding Retropharyngeal Hematoma After Fall from Height.

CASE PRESENTATION: An elderly man presented to the emergency department after a fall from a 15-foot height. Initial examination revealed signs of head and neck trauma without airway compromise. Computed tomography imaging identified cervical fractures at the first and second level with a retropharyngeal hematoma. In discussion with the trauma service, the patient was admitted to the hospital for airway monitoring. After 10 hours he clinically deteriorated, resulting in acute respiratory failure, and ultimately required intubation. The patient was intubated with a hyperangulated video laryngoscopy, and a surgical set-up was also prepared. The intubation was uncomplicated and resulted in clinical improvement. The patient was extubated after three days without difficulty and was ultimately discharged following an uncomplicated hospital course. DISCUSSION: Retropharyngeal hematoma is a rare but significant clinical condition. Rapid decline and airway compromise have been described. Patients often require intubation and mechanical ventilation to avoid airway obstruction and respiratory failure. Coagulopathies should be reversed, if present. Prompt recognition and treatment of this condition is crucial to successful management.

Ischemic ST-Segment Depression Maximal in V1-V4 (Versus V5-V6) of Any Amplitude Is Specific for Occlusion Myocardial Infarction (Versus Nonocclusive Ischemia).

Background Occlusion myocardial infarctions (OMIs) of the posterolateral walls are commonly missed by ST-segment-elevation myocardial infarction (STEMI) criteria, with >50% of patients with circumflex occlusion not receiving emergent reperfusion and experiencing increased mortality. ST-segment depression maximal in leads V1-V4 (STDmaxV1-4) has been suggested as an indicator of posterior OMI. Methods and Results We retrospectively reviewed a high-risk population with acute coronary syndrome. OMI was defined from prior studies as a culprit lesion with TIMI (Thrombolysis in Myocardial Infarction) 0 to 2 flow or TIMI 3 flow plus peak troponin T >1.0 ng/mL or troponin I >10 ng/mL. STEMI was defined by the Fourth Universal Definition of Myocardial Infarction. ECGs were interpreted blinded to outcomes. Among 808 patients, there were 265 OMIs, 108 (41%) meeting STEMI criteria. A total of 118 (15%) patients had "suspected ischemic" STDmaxV1-4, of whom 106 (90%) had an acute culprit lesion, 99 (84%) had OMI, and 95 (81%) underwent percutaneous coronary intervention. Suspected ischemic STDmaxV1-4 had 97% specificity and 37% sensitivity for OMI. Of the 99 OMIs detected by STDmaxV1-4, 34% had <1 mm ST-segment depression, and only 47 (47%) had accompanying STEMI criteria, of which 17 (36%) were identified a median 1.00 hour earlier by STDmaxV1-4 than STEMI criteria. Despite similar infarct size, TIMI flow, and coronary interventions, patients with STEMI(-) OMI and STDmaxV1-4 were less likely than STEMI(+) patients to undergo catheterization within 90 minutes (46% versus 68%; P=0.028). Conclusions Among patients with high-risk acute coronary syndrome, the specificity of ischemic STDmaxV1-4 was 97% for OMI and 96% for OMI requiring emergent percutaneous coronary intervention. STEMI criteria missed half of OMIs detected by STDmaxV1-4. Ischemic STDmaxV1-V4 in acute coronary syndrome should be considered OMI until proven otherwise.