Ovarian torsion masquerading as a ureteral stone.

BACKGROUND: Abdominal pain is the most common complaint within the emergency department (ED) and has many varied etiologies. Some of these conditions can be medical emergencies, including ovarian torsion. While representing just 3% of gynecologic emergencies, ovarian torsion should be considered in all females presenting to the ED with abdominal or pelvic complaints. CASE: A 38-year-old G5P5 female with a past medical history significant for ureterolithiasis presented to a freestanding ED with abdominal pain, nausea, and vomiting. She developed sudden onset of right sided abdominal pain radiating to her right flank upon awakening. The initial differential diagnosis was for ureterolithiasis or appendicitis. Her complete blood count (CBC) was normal, and testing for pregnancy, infection, and hematuria was negative. Computed topography (CT) imaging of the abdomen and pelvis revealed a 9 cm adnexal mass, consistent with a possible dermoid cyst. A pelvic ultrasound was ordered which showed a possible ovarian torsion. She was transferred to a tertiary care hospital where she had a laparoscopy with right-sided oophorectomy and salpingectomy performed. DISCUSSION: This patient presented with abdominal pain, nausea, and vomiting and was first suspected to have ureterolithiasis or appendicitis. She was found to have an ovarian torsion with a dermoid cyst, which resulted in the loss of her ovary and fallopian tube. This case demonstrates the importance of including gynecologic emergencies in the differential on all female patients presenting with abdominal pain.

Ultrasound-guided erector spinae nerve block for relief of endometriosis pain in the emergency department.

Endometriosis is a debilitating chronic condition often accompanied by severe pelvic pain and infertility issues. When outpatient medical management is not adequate, controlling pain can be challenging for providers in the acute setting. We report the case of a 23-year-old female with a past medical history of endometriosis who presented to a freestanding emergency department with a chief complaint of 10/10 pelvic pain on a numeric rating scale. She had tried non-steroidal inflammatory medications and heat with no success. The patient had medication intolerances to opioid analgesics and was given ketorolac intramuscularly with no relief of her pain. The emergency physician discussed and offered to perform an erector spinae plane nerve block (ESPB) for pain relief. Ultrasonography was utilized for visualization of landmarks with a curvilinear transducer; a 20-gauge Pajunk® Sonoplex needle was used to inject a total of 100 mg bupivacaine 0.25% without epinephrine along with dexamethasone 10 mg under the bilateral erector spinae fascial planes at the T9 level. Post-procedure, the patient had significant improvement in pain and rated it a 2/10. Utilizing nerve blocks for endometriosis and other chronic pelvic pain in the acute care setting can serve as an effective alternative to opioids. In patients with multiple medication intolerances and for providers navigating pain control in the setting of a nationwide opioid crisis, ESPB blocks can help alleviate acute pain or exacerbations of chronic pain. This case demonstrates the first known use of an ESPB to relieve endometriosis pain in the emergency department.

Ultrasound-guided erector spinae nerve block for relief of chest pain from pneumonia in the emergency department.

Erector spinae plane blocks (ESPB) have shown to provide meaningful chest wall anesthesia and reduce opioid consumption after thoracic surgery. Emergency physicians often use erector spinae plane blocks in the emergency department (ED) for rib fractures when acetaminophen, non-steroidal anti-inflammatory (NSAID), and opioids fail to control pain. They have also demonstrated successful pain management for conditions like herpes zoster, renal colic, burns, and acute pancreatitis for ED patients. With low reported rates of complication and relatively easy landmarks to identify, erector spinae plane blocks are an appealing regional anesthetic technique for emergency physicians to utilize for uncontrolled pain. We present the case of a 58-year-old male presenting to the ED with chest pain from pneumonia which remained unmanageable after acetaminophen, NSAID, and opioid administration. An ultrasound-guided erector spinae plane block was performed in the ED and the patient had a significant reduction in his chest pain.

Metformin-Associated Lactic Acidosis-Is This on Your Radar?

BACKGROUND: Metformin is a biguanide hyperglycemic agent used to manage non-insulin-dependent diabetes mellitus. Adverse reactions include mainly mild gastrointestinal adverse effects, but severe complications, such as metformin-associated lactic acidosis (MALA) can occur. Metformin is excreted renally and, therefore, not recommended in patients with renal impairment. The reported incidence of MALA is 3 cases per 100,000 patient-years. CASE REPORT: A 79-year-old woman with a complex medical history, including end-stage renal disease on dialysis and type 2 diabetes, presented to the emergency department (ED) for altered mental status. Prior to arrival, she was found to be hypoglycemic. Her laboratory results were significant for creatinine of 6.56 mg/dL and an anion gap of 52 mmol/L. The venous blood gas revealed a venous pH of 6.857 [reference range (7.32-7.43)], pCO2 of 15.9 mm Hg (40.6-60 mm Hg), HCO3 of 2.7 mmol/L (21-30 mmol/L), lactate of 27 mmol/L (0.5-2 mmol/L), and ammonia of 233 µmol/L. The patient was dialyzed emergently in the ED; repeat laboratory test results showed blood urea nitrogen of 10 mg/dL, creatinine of 1.65 mg/dL, carbon dioxide of 26 mmol/L, and anion gap of 13 mmol/L. The repeat ammonia was 16 µmol/L. The patient's metabolic encephalopathy resolved, and she was discharged home on hospital day 3. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MALA has a high mortality rate (36%). Laboratory markers have not been found to be a reliable predictor of mortality. Sodium bicarbonate is controversial, but a pH < 7.15 indicates consideration of its use. A pH < 7.1 and a lactate level > 20 mmol/L indicate the need for emergent hemodialysis. Prompt recognition and management in the ED with early hemodialysis can result in good patient outcomes, with a return to their baseline function despite severe laboratory findings.

The impact of COVID-19 on emergency department boarding and in-hospital mortality.

INTRODUCTION: The COVID-19 pandemic has been challenging for healthcare systems in the United States and globally. Understanding how the COVID-19 pandemic has impacted emergency departments (EDs) and patient outcomes in a large integrated healthcare system may help prepare for future pandemics. Our primary objective was to evaluate if there were changes to ED boarding and in-hospital mortality before and during the COVID-19 pandemic. METHODS: This was a retrospective cohort study of all patients ages 18 and over who presented to one of 17 EDs (11 hospital-based; 6 freestanding) within our healthcare system. The study timeframe was March 1, 2019- February 29, 2020 (pre-pandemic) vs. March 1, 2020-August 31, 2021 (during the pandemic). Categorical variables are described using frequencies and percentages, and p-values were obtained from Pearson chi-squared or Fisher's exact tests where appropriate. In addition, multiple regression analysis was used to compare ED boarding and in-hospital mortality pre-pandemic vs. during the pandemic. RESULTS: A total of 1,374,790 patient encounters were included in this study. In-hospital mortality increased by 16% during the COVID-19 Pandemic AOR 1.16(1.09-1.23, p < 0.0001). Boarding increased by 22% during the COVID-19 pandemic AOR 1.22(1.20-1.23), p < 0.0001). More patients were admitted during the COVID-19 pandemic than prior to the pandemic (26.02% v 24.97%, p < 0.0001). Initial acuity level for patients presenting to the ED increased for both high acuity (13.95% v 13.18%, p < 0.0001) and moderate acuity (60.98% v 59.95%, p < 0.0001) during the COVID-19 pandemic. CONCLUSION: The COVID-19 pandemic led to increased ED boarding and in-hospital mortality.

Spontaneous Expulsive Suprachoroidal Hemorrhage.

BACKGROUND: Spontaneous Expulsive Suprachoroidal Hemorrhage (SESCH) is an extremely rare phenomenon that leads to atraumatic spontaneous globe rupture. Only a handful of SESCH cases have been reported worldwide, primarily in developing countries. Risk factors associated with SESCH include uncontrolled hypertension, previous eye surgery, glaucoma, atherosclerosis, advanced age, and corneal damage. CASE REPORT: We report a case of expulsive suprachoroidal hemorrhage in a ninety-seven-year-old female. The patient presented to the emergency department with painful bleeding from her right eye. She denied any trauma or injury to the eye. She denied any use of anticoagulation. Physical examination showed a right ocular hematoma with mild active bleeding. She had exophthalmos and proptosis with extrusion of the ocular structures. A computed tomography scan of the orbits demonstrated right globe rupture with diffuse hemorrhage. Ophthalmology was consulted, and the patient subsequently had an evisceration of her right eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous expulsive choroidal hemorrhage is exceedingly rare. SESCH predominantly affects diseased eyes in the elderly. Early recognition of impending globe rupture in patients who present with suprachoroidal hemorrhage is necessary and requires prompt ophthalmology consultation. Emergency physicians must be aware that an atraumatic open globe can occur and requires immediate evaluation by an ophthalmologist and emergent repair in the operating suite.

Universal suicide screening in emergency departments across a large healthcare system.

BACKGROUND: Suicidal ideation is a common complaint in Emergency Departments (EDs) across the United States (US) and is an important preventable cause of death. Consequently, current Joint Commission guidelines require screening high-risk patients and those with behavioral health needs for suicide. Accordingly, we implemented universal suicide screening for all patients presenting to EDs in our healthcare system and sought to describe the characteristics of the identified "high-risk" patients. We also sought to determine whether universal suicide screening was feasible and what its impact was on ED length of stay (LOS). METHODS: All ED encounters in the healthcare system were assessed. Data were collected from February 1, 2020, through June 30, 2022. All patients aged 18 and over were screened using the Columbia Suicide Severity Rating Scale (C-SSRS) and categorized as no risk, low risk, moderate risk, and high risk. Encounters were then grouped into 'high risk" and "not high risk," defined as no, low, and moderate risk patients. Data collected included gender, discharge disposition, LOS, and insurance status. RESULTS: A total of 1,058,735 patient encounter records were analyzed. The "high risk" group (n = 11,359; 10.7%) was found to have a higher proportion of male patients (50.9 vs 43.7%) and government payors (71.6 vs. 67.1%) and a higher ED LOS [medians 380 min vs. 198 min] than the not high-risk group (p ≤0.001). Those with suicidal ideation comprised 0.73-1.58% of ED encounters in a given month. A secondary analysis of 2,255,616 ED encounter records from January 2019 - June 30, 2022, revealed that 40,854 (1.81%) encounters required 1:1 observation. The proportion of 1:1 observations in 2019, the year before implementation, was 1.91%. Using a non-inferiority margin of 25%, we found that the proportion of 1:1 patients in 2020, the year following implementation, was non-inferior to (no worse than) the previous year at 2.09% and decreased from 2021 to 2022 (1.69% and 1.57% respectively). CONCLUSION: Implementing universal suicide screening in all EDs within a healthcare system is feasible. The percentage of patients who screened high risk was under 5% of the overall ED population. While the median LOS was longer for "high-risk" patients than for the general ED population, it was not excessively so. Adequate staffing to properly maintain the safety of these patients is paramount.

Transversus abdominis plane (TAP) block for pain management of rectus sheath hematoma in the emergency department (ED).

Peripheral nerve blocks for pain management have historically been discussed in anesthesiology literature but, until recently, have not been considered in emergency medicine contexts. Transversus abdominis plane (TAP) blocks, in particular, have recently been explored in the emergency department for pain control in acute appendicitis but are potentially helpful for managing abdominal pain of other etiologies. One such pathology is rectus sheath hematomas, where conservative management is often necessary as curative treatments often pose more significant risks than are necessary. We report the case of a 57-year-old female presenting to the emergency department with severe abdominal pain following vigorous exercise. She was found to have a large rectus sheath hematoma on computed tomography. An ultrasound-guided transversus abdominis plane block was performed in the emergency department, and the patient had complete resolution of her pain.

Evaluation of missed influenza vaccination opportunities in the emergency department.

BACKGROUND: Seasonal influenza is associated with significant healthcare resource utilization. An estimated 490,000 hospitalizations and 34,000 deaths were attributed to influenza during the 2018-2019 season. Despite robust influenza vaccination programs in both the inpatient and outpatient setting, the emergency department (ED) represents a missed opportunity to vaccinate patients at high risk for influenza who do not have access to routine preventive care. Feasibility and implementation of ED-based influenza vaccination programs have been previously described but have stopped short of describing the predicted health resource impact. The goal of our study was to describe the potential impact of an influenza vaccination program in an urban adult emergency department population using historic patient data. METHODS: This was a retrospective study of all encounters within a tertiary care hospital-based ED and three freestanding EDs during influenza season (defined as October 1 - April 30) over a two-years, 2018-2020. Data was obtained from the electronic medical record (EPIC®). All ED encounters during the study period were screened for inclusion using ICD 10 codes. Patients with a confirmed positive influenza test and no documented influenza vaccine for the current season were reviewed for any ED encounter at least 14 days prior to the influenza-positive encounter and during the concurrent influenza season. These ED visits were deemed a missed opportunity to provide vaccination and potentially prevent the influenza-positive encounter. Healthcare resource utilization, including subsequent ED encounters and inpatient admissions, were evaluated for patients with a missed vaccination opportunity. RESULTS: A total of 116,140 ED encounters occurred during the study and were screened for inclusion. Of these, 2115 were influenza-positive encounters, which represented 1963 unique patients. There were 418 patients (21.3%) that had a missed opportunity to be vaccinated during an ED encounter at least 14 days prior to the influenza-positive encounter. Of those with a missed vaccination opportunity, 60 patients (14.4%) had subsequent influenza-related encounters, including 69 ED visits and 7 inpatient admissions. CONCLUSION: Patients presenting to the ED with influenza frequently had opportunities to be vaccinated during prior ED encounters. An ED-based influenza vaccination program could potentially reduce influenza-related burden on healthcare resources by preventing future influenza-related ED encounters and hospitalizations.

Computed Tomography Utilization for Patients Presenting with Chest Pain.

INTRODUCTION: Computed tomography (CT) is routinely used in the emergency department (ED) due to its ease of access and its ability to rapidly rule in or out many serious conditions. Freestanding emergency departments (FSEDs) have become increasingly used as an alternative to hospital-based emergency departments (HBEDs). The objective of this study was to investigate if the utilization rate of CT differs between FSEDs and HBEDs for chest pain. METHODS: A retrospective evaluation of patients presenting to 17 EDs within a large integrated healthcare system between May 1, 2019 - April 30, 2021 with a chief complaint chest pain. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation. Multiple logistic regression was used to assess the effect of facility on CT utilization for chest pain. RESULTS: There were 67,084 patient encounters included in the study. Patients were predominately female (55%), white (61%), and insured through Medicare/Medicaid (59%). After controlling for predictive variables which included Charlson Comorbidity Index, ESI, age, sex, and race, patients who presented to FSEDs with chest pain were less likely to have a CT than those who presented to a HBED (AOR = 0.85, CI (0.81-0.90). CONCLUSION: CT scans of the chest are utilized less frequently at FSEDs compared to HBEDs for patient presenting with chest pain.

Patients utilizing emergency medical services - Does facility type matter?

BACKGROUND: Emergency departments (EDs) play a critical role in the US healthcare system. As freestanding EDs (FSEDs) are integrated into the acute care landscape, local EMS providers are transporting to these facilities, which may be closer in proximity and provide faster turnaround times. We hypothesized that patients transported via EMS to a freestanding ED required fewer tests and are admitted less frequently than those transported to a HBED. Our objective was to compare testing frequency and admission rates between patients transported via EMS to a FSED vs. HBED. METHODS: This was a retrospective cohort study of all patients who presented within a large integrated hospital system via EMS to one of 10 HBEDs or one of 6 FSEDs between April 1, 2020 - May 1, 2021. Categorical variables are presented as frequencies and percentages and comparisons between groups were obtained using chi squared tests. Continuous variables are presented as mean and standard deviation and p-values comparing groups were obtained using t-tests. Multiple logistic regression was used to assess the effect of ED type on admission status, labs ordered, and testing performed. RESULTS: A total of 123,120 encounters were included in our study. Mean age at the FSEDs was 59.9 vs. 61.3 at the HBEDs. At the FSEDs 55.6% (n = 4675) were female vs. 53.0% (n = 60,809) at the HBEDs. At the FSEDs 82.0% (n = 6805) were White vs. 60.7% (n = 68,430) at the HBEDs. We found 50.0% (n = 3974) had Medicare at the FSEDs vs 50.9% (n = 55,372) at the FSEDs. At the FSEDs, 69.5% (n = 5846) had bloodwork vs. 82.4% (n = 94,512) at the HBEDs; 68.3% (n = 5745) had an x-ray at the FSEDs vs. 70.7% (n = 81,089) at the HBEDs; 40.1% (n = 3370) had a CT scan at the FSEDs vs. 44.9% (n = 51,503) at the HBEDs; and 40.6% (n = 3412) were admitted at the FSEDs vs. 56.1% (n = 64,355) at the HBEDs. After controlling for Charlson Comorbidity Index, acuity, age, gender, sex, insurance and race, patients in FSEDs were 35% less likely to be admitted as compared to HBEDs. CONCLUSION: Patients brought in via EMS to a FSED were less likely to have blood work, x-ray, or CT scan, and were less likely to be admitted to the hospital than those transported to a HBED.

Primary Neurologic Symptoms: Have You Considered Pernicious Anemia?

BACKGROUND: Vitamin B12, or cobalamin, is a nutrient that is vital for metabolic function. Absorption of ingested B12 is dependent on intrinsic factor, which is secreted by parietal cells within the stomach. Pernicious anemia is caused by an intrinsic factor deficiency or autoantibodies against intrinsic factor. The presence of parietal cell antibodies can destroy parietal cells, which can also lead to a deficiency in intrinsic factor. Both lead to megaloblastic anemia caused by vitamin B12 deficiency. The typical presentation of pernicious anemia includes fatigue, pale appearance, tingling sensation, depression, alterations to vision and smell, urinary incontinence, psychotic episodes, and weakness. The most effective treatment for pernicious anemia is intramuscular B12. CASE REPORT: A 27-year-old woman with a history of vitiligo presented to the emergency department (ED) with bilateral lower extremity weakness, clumsiness, numbness, and tingling. Physical examination revealed ataxia, no sensation below her umbilicus, decreased strength, and hyperreflexia in both lower extremities. Complete blood count in the ED revealed low hemoglobin and hematocrit and elevated mean corpuscular volume, concerning for pernicious anemia. Further laboratory testing upon inpatient admission revealed a low vitamin B12 level and parietal cell antibodies in the blood. The patient's pernicious anemia was treated with intramuscular vitamin B12 injections, which led to near complete resolution of her symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early suspicion and detection of pernicious anemia in the ED can prevent serious and permanent hematologic and neurologic damage and the development of other autoimmune disorders.

Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban.

BACKGROUND: Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior chamber of the eye without a predisposing traumatic event. Hyphema can be associated with acute elevations in intraocular pressure in up to 30% of cases, which poses a significant risk for permanent vision loss if not quickly recognized and treated in the emergency department (ED). Anticoagulant and antiplatelet medications have been previously associated with cases of spontaneous hyphema; however, there are limited reports of hyphema with associated acute glaucoma in a patient taking a direct oral anticoagulant. Due to the limited data of reversal therapies for direct oral anticoagulants in intraocular hemorrhage, these patients pose a challenge in deciding whether to reverse anticoagulation in the ED. CASE REPORT: We present a case of a 79-year-old man on apixaban anticoagulation therapy who presented to the ED with spontaneous painful vision loss in the right eye with associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage, and tonometry was significant for acute glaucoma. As a result, the decision was made to reverse the patient's anticoagulation with four-factor activated prothrombin complex concentrate. Why Should an Emergency Physician Be Aware of This? This case is an example of acute secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence regarding anticoagulation reversal in this setting. A second site of bleeding was identified by utilization of point-of-care ultrasound, which led to the diagnosis of a vitreous hemorrhage. This allowed for shared decision-making between the emergency physician, ophthalmologist, and patient regarding the risks and potential benefits of the reversal of anticoagulation. Ultimately, the patient decided to have his anticoagulation reversed to try and preserve vision.

Do racial disparities exist at various time points during an emergency department visit for chest pain.

INTRODUCTION: It is well documented that disparities in patient care based on race and ethnicity are prevalent in the emergency medical care setting. In most cases these evaluations are patient focused and outcome based. The timeliness of patient treatment in the emergency department (ED) is correlated with patient outcomes. In this study, we sought to evaluate whether the timeliness of care for patients with chest pain across stages of care was impacted by patient race. METHODS: This was a retrospective evaluation of ED throughput times including adults who presented to one of seventeen EDs in a large healthcare system from January 1, 2019 to December 31, 2019 and met criteria for inclusion. The effect of race on different intervals of care were assessed. Generalized Linear Models were used to estimate the effect of race on different intervals of care while controlling for Charlson Comorbidity index, age, gender, insurance, ED facility type and emergency severity index acuity level. RESULTS: A total of 28,705 patients were included, with a mean age of 54 ± 18 years. The majority of patients were White (63%), female (56%) and had Medicare or Medicaid (56%). Black patients experienced significantly increased wait times for resident physician examination, advanced practice provider examination, attending physician examination, and ED disposition. There was no difference in time to triage between Black patients and White patients. CONCLUSION: Black patients have longer wait times for resident physician evaluation, advanced practice provider evaluation, attending physician evaluation, and ED disposition when presenting to the ED with chest pain.

Acute transverse myelitis progressing to permanent quadriplegia following COVID-19 infection.

As of January 2022, there have been over 350 million confirmed cases of COVID-19 in the world. The most common symptoms in those infected are fever, cough, malaise, and myalgia, however pulmonary, hematologic, gastrointestinal, renal, and neurologic complications have also been reported. Acute transverse myelitis (ATM) is an uncommon neurological syndrome characterized by acute or subacute spinal cord dysfunction that can lead to paresthesias, sensory and autonomic impairment, and even paralysis. Etiologies are often unclear; however, potential causes include infection, neoplastic, drug or toxin induced, autoimmune, and acquired. Treatment for ATM primarily consists of steroids and plasmapheresis, which often reverses any neurologic symptoms. ATM has rarely been reported as a complication of COVID-19 infections. A 43-year-old female presented to the emergency department for evaluation of progressive numbness and tingling in her legs ten days after developing upper respiratory symptoms from a COVID-19 infection. Physical examination and magnetic resonance imaging confirmed a diagnosis of ATM. During her hospital course, she experienced rapid progression of her paresthesias and developed complete loss of motor function in her upper and lower extremities. Within 48 hours after emergency department arrival, she required intubation due to worsening diaphragmatic and chest wall paralysis. Her treatment included a long-term steroid regimen and plasmapheresis, and unfortunately, she did not have any neurologic recovery. We present a very rare case of ATM progressing to complete quadriplegia following COVID-19 infection.

Improved hospital mortality rates after the implementation of emergency department sepsis teams.

INTRODUCTION: Sepsis is a leading cause of mortality with more than 700,000 hospitalizations and 200,000 deaths annually in the United States. Early recognition of sepsis is critical for timely initiation of treatment and improved outcomes. We sought to evaluate. in-hospital mortality rates of patients diagnosed with sepsis before and after implementation of emergency department (ED) sepsis teams. METHODS: This was a retrospective study of adult patients seen at a tertiary care ED diagnosed with sepsis and severe sepsis. Pre-implementation study time frame was 5/1/2018-4/30/2019 and post-implementation was 11/1/2019-9/30/2020. A six-month washout period was utilized after implementation of ED-based sepsis teams. Indications for sepsis team activation were: two systemic inflammatory response syndrome (SIRS) criteria with suspected infection or two SIRS with confirmed infection during workup. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviation or median and quartiles depending on distribution. Multiple logistic regression compared mortality rates pre- and post-implementation while controlling for Charlson comorbidity index. Secondary objectives included comparing time metrics pre- and post-implementation. Student t-tests compared normally distributed variables and Wilcoxon rank sum tests compared non-normally distributed variables. RESULTS: There were 1188 participants included in the study; 553 before implementation of sepsis teams and 635 after implementation. Mean age of participants was 64 years. Patients were 74.7% white and 22.6% black. Medicare was the most common health insurance (59%). Mortality rates were significantly lower post-implementation of sepsis teams compared to pre-implementation with an adjusted odds ratio of 0.472, (95%CI, 0.352-0.632). ED LOS (95%CI (-67.2--11.3), hospital LOS (95%CI, -1.0--0.002) and time to lactic acid (95%CI, -10.0- -3.0) and antibiotics (95%CI, -29.0--11.0) were all significantly lower after implementation. CONCLUSION: Implementation of ED sepsis teams decreased inpatient hospital mortality rates, ED length of stay and hospital length of stay.

Complete Neurological Recovery After Emergency Burr Hole Placement Utilizing EZ-IO® for Epidural Hematoma.

BACKGROUND: Post-traumatic epidural hematoma (EDH) accounts for 1-3% of pediatric closed head injury admissions. There is a 2.5:1 male predominance. Etiology varies by age; motor vehicle collisions are the primary cause of EDH in adolescents. Post-traumatic EDH accompanies up to 4% of adult head injuries, and is associated with 10% mortality in adults and 5% mortality in children. In North America, standard of care for post-traumatic EDH includes decompressive craniotomy or trepanation via burr hole. Such lifesaving care is typically provided in the operating room by consulting neurosurgery teams or other personnel trained in the use of burr hole equipment. CASE REPORT: The case of a 17-year-old female patient who presented to a community emergency department (ED) after being involved in a motor vehicle collision is discussed. At the scene of the accident, she refused emergency medical services transport and was brought to the ED via private vehicle. She quickly decompensated in the ED and required intubation. Neurosurgical services were not available and transport to the nearest pediatric trauma center was delayed due to weather. Decompression and drainage of her EDH was accomplished with an EZ-IO® driver and intraosseous needle under virtual guidance of a pediatric neurosurgeon until definitive care could be obtained. The patient made a full neurologic recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS: EDHs have high morbidity and mortality. In settings without access to neurosurgical services, and where ED access to or familiarity with burr hole equipment is limited, the EZ-IO® device may be a temporizing and lifesaving intervention until definitive neurosurgical care can be obtained.

Thrombotic Thrombocytopenic Purpura after Ad26.COV2-S Vaccination.

The U.S. Food and Drug Administration (FDA) recently issued an Emergency Use Authorization (EUA) for two highly effective Sars-CoV-2 (COVID-19) vaccines from Pfizer-BioNTech and Moderna. More recently, EUA was granted for the Johnson and Johnson COVID-19 vaccine which uses traditional virus-based technology. In this vaccine, researchers added the gene for the coronavirus spike protein to modified Adenovirus 26 and named it Ad26.COV2-S. Nearly 7 million doses of the Ad26.COV2-S have been administered as of mid-April 2021. Recently the Federal Drug Administration and Center for Disease Control and Prevention reviewed data involving six reported cases in the United States of cerebral venous sinus thrombosis in combination with thrombocytopenia in people who received the vaccination. All cases were in women between 18 and 48, with symptoms developing six to 13 days after vaccination. A recent study in the United Kingdom reported similar events in 23 patients age 21 to 77, 61% of which were female, with cases of presumed vaccine induced thrombosis and thrombocytopenia occurring six to 24 days after vaccination. We report a 62-year-old female who presented to the emergency department (ED) with acute onset of altered mental status. She had received the Ad26.COV2-S vaccine 37 days prior to ED presentation. She developed thrombotic thrombocytopenic purpura (TTP) and no other cause was found. To our knowledge this is the first case in the United States of thrombotic thrombocytopenic purpura after receiving the Ad26.COV2-S COVID-19 vaccine.

Intraocular mass as first presenting symptom of metastatic squamous cell lung cancer.

Lung cancer is one of the leading causes of cancer related mortality worldwide. Currently, it is the third most common cancer behind prostate and breast cancer. Approximately 85% of all lung cancers are non-small-cell lung cancers (NSCLC). Adenocarcinoma and squamous cell carcinoma are the most common subtypes, accounting for 50% and 30% of NSCLC cases, respectively. Lung cancer is often initially found on chest x-rays and diagnosed via biopsy of the lesion. It is often diagnosed at the time of advanced or metastatic disease. The majority of lung cancers metastasize to locations such as bone, brain, adrenal glands and liver. Multiple case reports have been reported with ocular metastases, such as the choroid, iris and retina. We present a 87-year-old women whose initial emergency department presentation of squamous cell type lung cancer was an intraocular mass. To our knowledge this is the first reported case of this presentation and diagnosis within the emergency department setting.

Myocarditis after BNT162b2 vaccination in a healthy male.

Myocarditis following mRNA COVID-19 vaccination has recently been reported to health authorities in the United States and other countries. Cases predominately occur in young adult males within four days following the second dose of either the Moderna (mRNA-1273) or Pfizer-BioNTech (BNT162b2) vaccines. Although the number of cases reported have been small in comparison with the large number of people vaccinated, myocarditis may be a rare adverse reaction to the COVID-19 vaccination that is now only becoming apparent due to the widespread use of the vaccine. In this article, we present a case of a 20-year-old male with no prior medical history who presented to the emergency department (ED) with chest pain. He had received the BNT162b2 vaccine two days prior to his presentation to the ED. The patient had an elevated troponin at 89 ng/L which increased on repeat examination. His electrocardiogram showed diffuse concave ST segment elevations and a later MRI confirmed the diagnosis of myocarditis. Based on these findings, the patient was diagnosed with myocarditis. The patient had a previous infection with SARS-CoV-2 approximately two months prior to the onset of his symptoms, but since he had fully recovered before the time of his presentation to the ED, it is unlikely that the infection caused the myocarditis. To our knowledge, this is the first published case of myocarditis following BNT162b3 vaccination.