Post-Traumatic Intracranial Pseudoaneurysm Presenting as Epistaxis.

Background: Epistaxis is a frequent presenting complaint in the Emergency Department (ED). Roughly 60% of the population will suffer from epistaxis in their lifetime. The most common causes of epistaxis include nose picking, facial trauma, foreign bodies, and coagulopathies. There are other causes that are much less common, such as intracranial pseudoaneurysms. There are multiple causes that precipitate intracranial pseudoaneurysm formation, with head trauma accounting for less than 1% of inciting events. Case Report: A 24-year-old female with history of traumatic brain injury with associated skull fractures due to a gunshot wound to the head 6 months prior presented to the ED in hemorrhagic shock secondary to epistaxis. After stabilization with the administration of blood products, Computed Tomography with Angiography (CTA) imaging of the head and neck was obtained and revealed a 3.1 × 2.2 × 2.5 cm pseudoaneurysm of the cavernous portion of the right internal carotid artery penetrating through the base of the skull into the ethmoidal sinus. The patient was taken for formal angiography by interventional radiology-and a partially thrombosed daughter sac of the initial aneurysm was identified and believed to be the source of the hemorrhage. The aneurysm was successfully coiled and occluded using ONYX embolization. Postoperatively, the patient returned to her baseline mental status without any acute complaints. The patient was discharged back to her nursing home 2 days later with a 3-week follow-up CTA revealing persistent occlusion of the aneurysm and a patent internal carotid artery. Conclusion: Awareness and consideration of intracranial vascular etiology for common complaints in the emergency room, such as Epistaxis, especially in patients with any history of head injury/trauma, known intracranial aneurysms or prosthetic devices from prior surgery may help guide decision-making in managing critically ill patients.

Potential anaphylactoid reaction to nicardipine.

Anaphylactic and anaphylactoid reactions are both acute allergic responses known to be potentially fatal if not treated emergently. Signs include bronchospasm, urticaria, nausea and vomiting, pharyngeal edema and cardiovascular collapse. Nicardipine hydrochloride is a dihydropyridine calcium channel blocker that has emerged as a first-line antihypertensive in which emergent blood pressure control is critical. The patient in this case is a 52-year-old male who arrived at the emergency department (ED) with right-sided hemineglect, severe dysarthria, and aphasia, and he was diagnosed with an acute left thalamic hemorrhage. His blood pressure readings were initially 252/135 mmHg despite multiple intermittent boluses of intravenous hydralazine. He was administered a nicardipine hydrochloride infusion at 2.5 mg/h. Due to poor blood pressure control, the rate was titrated up in increments of 2.5 mg/h in the span of 30 min. While up titrating the infusion rate, he developed diffuse swelling and erythema to his left upper extremity in which the medication was being infused, a body wide urticarial rash, tachycardia, diaphoresis, wheezing, and hypoxemia saturating 85% on room air.

Upper Extremity Musculoskeletal Injuries Presenting to an Emergency Department Before and During the Initial COVID-19 Pandemic Surge.

Study Objective: The SARS-CoV-2 (COVID-19) pandemic significantly impacted emergency department volume and acuity. The Delta and Omicron variants contributed to additional surges. We describe the impact that the initial pandemic phase had on frequency and severity of typically non-life-threatening emergencies using upper extremity injuries as a model for other potentially emergent presentation as compared to pre-pandemic times. We do this using the epidemiology of pre-defined significant upper extremity injuries at our facility as a specific example of what occurred at an urban trauma center. Methods: We conducted a comparison of two 6-month periods: between March 2019 and August 2019 (prior to COVID-19) and between March 2020 and August 2020 after the onset of the initial COVID-19 wave. We performed a retrospective chart review of patients who presented with upper extremity injury chief complaints using analysis of the electronic medical record at a single urban tertiary care trauma center in the Midwestern United States. We investigated examination findings, imaging, frequency of surgical procedures and final diagnosis. Results: In the 2019 study period, there were 31,157 ED patients, including 429 with upper extremity injuries, of which 108 patients had significant injuries. In the 2020 study period, there were 24,295 patient presentations, of which 118 of 296 upper extremity presentations were significant. We a priori defined significant injury as follows: fractures, dislocations, neurovascular injuries, or need for operative intervention within 24 hours of ED presentation. Specifically, 25.2% of injuries were significant pre-COVID-19 and 39.9% (p < 0.001) during the initial COVID-19 surge. The absolute number and percentage of significant injuries increased from pre-COVID-19 compared to the initial COVID-19 surge despite an overall 22% decrease in total patient volume. Conclusion: The incidence of significant upper extremity musculoskeletal injuries increased during the pandemic even though the overall number of ED presentations for upper extremity musculoskeletal injuries decreased.

How we use social media to supplement a novel curriculum in medical education.

BACKGROUND: The millennial learner is reliant on technology to gain knowledge. Social media in the form of Twitter and Facebook provide a unique way to reach these learners. AIMS: To demonstrate a supplement to a curriculum using "push technology" via Twitter and Facebook to deliver educational content to mobile devices. METHODS: A curriculum consisting of high-yield ultrasound concepts was developed and posted to Twitter @EDUltrasound daily. Followers received tweets "pushed" directly to their mobile devices. Following the year-long program, followers were surveyed regarding the program's effectiveness. To determine the ways in which tweets were reaching users, followers were categorized demographically. RESULTS: Daily "tweets" were posted each morning beginning on July 1, 2010. By the end of the year, there were 87 followers on Twitter and 78 on Facebook. The majority of followers (55.6%) had not previously used Twitter. The majority of followers (88.9%) found Twitter user-friendly, while most (81.5%) found the information useful. CONCLUSIONS: Due to ease of use and widespread applicability, Twitter and Facebook are excellent applications of "push technology" as a means to deliver educational content. This pilot project demonstrates the potential of social media to both supplement and enhance traditional educational methods.

Implementation of a Provider in Triage and Its Effect on Left without Being Seen Rate at a Community Trauma Center.

INTRODUCTION: Emergency department (ED) overcrowding is a nationally recognized problem and multiple strategies have been proposed and implemented with varying levels of success. It has caused patients to present to the ED but leave without being seen (LWBS). These patients suffer delayed diagnosis, delayed treatment, and ultimately increased morbidity and mortality. In efforts to decrease the number of patients who leave without being seen, one proposed solution is to place a provider in triage to evaluate these patients at the initial point of contact. METHODS: A retrospective chart review was conducted on patient's presenting to the Emergency Department from October through January for the years 2013 through 2017. A list of all patient dispositions for each study month was analyzed and compared for the 4 consecutive years with the implementation of an Advanced Practice Provider (APP) in triage. RESULTS: A total of 2162 patients dispositioned as LWBS during the entire study period of October 2013 through January 2017 were enrolled in the analysis. After implementation of a provider in triage, there was a 39% overall decrease (95% CI 0.005) in patients who left the ED before completion of treatment. There was a 69% reduction (95% CI 0.005) in patients who left before seeing the provider in triage. After seeing the provider, we saw an 83% reduction (95% CI<0.001) in LWBS. Overall, our initial LWBS rate was found to be 5%, and after implementation of a provider in triage that rate decreased to 1%. DISCUSSION: The addition of a provider in triage decreased our LWBS rate from 5% to 1%. The addition of a provider in triage also helped identify sick patients in the waiting room and helped facilitate more rapid assessment of ED patients on arrival.