JEM reports最新文献

Background

Emergency physician use of transesophageal echocardiography (TEE) is emerging as a promising tool to aid diagnosis and treatment during resuscitation.

Case report

We present a case of aVR ST-elevation myocardial infarction followed by witnessed cardiac arrest and diagnosis of aortic dissection by resuscitative TEE intra-arrest. We propose the aortic dissection caused severe aortic regurgitation, left ventricular outflow tract obstruction and coronary artery malperfusion due to intimal intussusception through the aortic valve, ultimately resulting in death.

Why should an emergency physician be aware of this?

Resuscitative TEE rapidly identified this unexpected life-threatening pathology and drastically changed patient management.

Background

The COVID-19 pandemic has made facial masks an essential part of daily life. While protective facial masks are crucial to help the spread of viral infections, they are common causes of facial skin breakdown, acne, and superficial injuries. Masks with elastic ear loops are also particularly likely to cause ear pressure injuries.

Case report

Herein, we present a case of a patient experiencing homelessness found to have significant postauricular wounds due to prolonged mask use in the context of the Covid-19 pandemic. These injuries led to bilateral erosion of the helix with partial avulsion of the ear and mask ear loops eroding into cartilage.

Why should an emergency physician be aware of this?

We describe a rare complication of mask use and highlight the difficulties the COVID pandemic has made in providing adequate care for chronic head and neck wounds amongst the homeless population. While PPE remains an important part of decreasing the risk of the spread of infections, it is important to recognize the vulnerabilities of the homeless population during the COVID pandemic and how best to care for novel auricular wounds.

Background

Interfacility transfer patients have poorer outcomes and greater resource needs than the average emergency department (ED) patient, however, trends in transfer rates remain poorly understood.

Objective

To quantify temporal trends in the volume of interfacility transfers to the emergency department of an academic referral center.

Methods

A retrospective review was performed of all adult patients transferred to the ED of a large, academic medical center in the Northeastern U.S. from 2017 to 2019. The mean transfer and total ED volumes by season, day of week, time of day, and federal holiday status were calculated and compared.

Results

A total of 26,555 adult patients were transferred to the hospital ED from 2017 to 2019. Transfer volume increased by 13% over the study period while total ED volume increased by less than 1%. While transfer patients made up, on average, only 8.6% of ED patients during day shifts, this proportion increased to 16.5% during evening shifts and 18.8% during night shifts. A modest, cyclical weekday pattern was also noted, with the proportion of ED volume from transfers reaching its highest on Saturdays and its lowest on Wednesdays. No consistent trends in transfer volume due to season or holiday status were observed.

Conclusion

Our center's significant two-year increase in interfacility transfer volume and relative stagnation in total ED volume illustrates an expanding role supporting community facilities. Consequently, transfer patients accounted for an increasing proportion of ED providers' workload during evening shifts and during overnight shifts. Referral centers may benefit from performing similar analyses of their own transfer volume to inform ED resource allocation.

Background

Diabetic ketoacidosis (DKA) is a rare complication of immune checkpoint inhibitor (ICI) therapy, a treatment used for many malignancies.

Case reports

We present two cases of adults, one without a prior history of diabetes, presenting to the Emergency Department (ED) with DKA induced by ICI therapy.

Why should an emergency physician be aware of this? The emergency physician should be aware of the spectrum of complications associated with ICI therapy, and should remain vigilant in patients presenting with symptoms of DKA and/or unexplained elevated anion gap metabolic acidosis, as DKA in patients without a history of diabetes mellitus can go unrecognized.

Background

Ultrasound-guided nerve blocks have been increasingly used in the emergency department (ED) to provide effective regional analgesia without relying on the use of systemic medications, which given in high quantities may cause respiratory depression. Ultrasound-guided nerve blocks of the superficial fibular nerve have been relatively understudied in the context of ED utilization.

Case report

We report the case of a 65-year-old woman with a history of acute lymphoblastic leukemia (ALL) on lifelong non-cytotoxic chemotherapy and sarcoma who presented with a chief complaint of right lower extremity pain for one week after minor trauma. She reported severe pain and was unable to bear weight. Her workup was negative for fracture, thrombus, compartment syndrome, and limb ischemia. Pain relief was not achieved even after the utilization of several doses of parenteral analgesics. After 12 hours in the ED, the patient was treated with an ultrasound-guided superficial fibular nerve block. Within one hour of treatment, she was able to ambulate and was discharged. During an oncology follow-up visit, she was found to have a recurrence of malignancy in her area of pain based on an outpatient bone scan and MRI. This case report demonstrates the successful utilization of a superficial fibular nerve block for refractory cancer-related pain.

Why should an emergency physician be aware of this?

Cancer-related refractory pain is one of the most difficult conditions to treat in the emergency department. Patients requiring multiple high doses of opioids and sedatives are at risk for airway compromise. Refractory pain related to cancer can lead to extended ED stays or hospital admission. This case study highlights the use of a superficial fibular nerve block for refractory cancer-related pain in the ED and details the technique for performing the procedure.

Background.

Distal radius fractures are a common Emergency Department (ED) presentation and often require procedural sedation for adequate pain control in order to facilitate closed reduction. Ultrasound-guided supraclavicular brachial plexus blocks are classically used for wrist and forearm surgeries, but have begun to be performed in the ED for distal radius fracture reductions. This procedure is not without its complications, including local anesthetic systemic toxicity, complications from needle insertion (peripheral nerve injury, vascular injury, pneumothorax), and phrenic nerve involvement leading to hemidiaphragmatic paralysis. This case series reviews using a single injection with a low volume of anesthetic to mitigate the risk of these complications.

Case Series

Three cases of distal radius fractures presented to the ED requiring reductions. Targeting the C8/T1 nerve roots, low-volume supraclavicular nerve blocks were performed. With concomitant non-opioid analgesia, closed reductions were performed with minimal reported pain. No complications were identified.

Why should an emergency physician be aware of this?

Patients requiring sedation often present to the ED with poorly controlled comorbidities or other contraindications making nerve blocks an excellent alternative. Contrary to the dense surgical anesthesia required by anesthesiologists, the emergency clinician should tailor the block to the specific pathology. In the case of distal radius fracture reductions, we recommend targeting the C8-T1 nerve roots. Through a single targeted injection with accompanying multimodal pain relief, adequate analgesia can be obtained while mitigating the risks that accompany high volume anesthetic and needle redirection.

Background

Local anesthetics are critical in the management of acute and chronic pain in various procedures and medical specialties. Their anesthetic properties derive from the ability to reversibly block sodium channels embedded within nerve fibers, and thus inhibit the conduction of painful stimuli from an affected area. In supratherapeutic dosing, local anesthetic toxicity is directly related to the drug's propensity to distribute systemically. Onset and amplitude of toxicity may be increased in the setting of inadvertent intra-circulatory injection. One toxic manifestation is the direct inoculation of local anesthetics within the central nervous system (CNS).

Case report

We present the case of a 34-year-old-female with neurotoxicity secondary to bupivacaine injection during a greater occipital nerve block. Emergent management of the patient required intubation, seizure control, and intravenous lipid emulsion therapy.

Why should an emergency physician be aware of this?

Direct central nervous system (CNS) toxicity from local anesthetics leads to rapid clinical decline and the need for extensive immediate resuscitative efforts. Early in the resuscitation, emergency physicians must recognize that the symptoms of local anesthetic toxicity require prompt specialty consultation with medical toxicologists and treatment with intralipid therapy to help reduce morbidity and mortality. Knowledge of toxic doses of local anesthetic and the dose related toxic effects can prompt recognition of either direct CNS or intra-vessel injection.

Background

When emergency department (ED) patients require a higher level of care, transferring patients for specialized services to another ED may be needed. Previous studies have characterized risks and cost factors involved with transfers; however, few have evaluated the appropriateness of transfers.

Objectives

The objective of this study was to determine if a specialty consultation or admission was required for ED-to-ED transfers.

Methods

This was a retrospective cohort of all adult patients aged 18 and older who presented one of 17 EDs between January 1, 2018, and December 31, 2020, and were transferred to another ED within the healthcare system. Categorical variables are presented as frequencies and percentages. Continuous variables are presented as mean and standard deviations or median and quartiles. Multiple logistic regression was utilized to determine if the variables collected were predictive of hospital admission.

Results

A total of 7486 encounters were included in the study. The mean age of participants was 54. Most patients were white (76.5%), male (50.6%), and had private insurance (39.0%). At the receiving ED, 64.0% (n ​= ​4750) received a specialty consult, and 61.3% (n ​= ​4549) were admitted to inpatient services. A total of 1430 (19.3%) patients did not receive a specialty consult and were discharged from the ED.

Conclusion

The majority all ED-to-ED transfers involved a specialty consultation, and 61.3% of patients transferred were admitted to the hospital. Further research to determine why patients did not require specialty consultation or admission may help reduce unnecessary transfers.