JEM reports最新文献

Background

Recent evidence suggests that intra-articular lidocaine (IAL) is an appropriate analgesic alternative to intravenous sedation (IV sedation) during shoulder dislocation reduction, however little is known about patient factors associated with IAL failure and need for subsequent IV sedation. Avoiding crossover is important, as repeated reduction attempts have been previously shown to increase the rate of procedural complications.

Objectives

To identify patient level factors associated with crossover from IAL to IV sedation and associated complication rates and operational impacts.

Methods

This retrospective observational cohort study evaluated the patient characteristics associated with crossover to unplanned IV sedation after IAL among adult patients undergoing ED reduction of an isolated, acute anterior shoulder dislocation from 2013 to 2021 in an urban, academic hospital system. Univariate analysis and multivariate logistic regression were used.

Results

In total, 630 participants were identified who received IAL or procedural sedation. Of these, 182 (28.9 ​%) received IAL of whom 49 (26.9 ​%) subsequently required unplanned IV sedation. Participants had 1.205 (95 ​% CI 1.030, 1.418) fold increase in odds of unplanned sedation for every 10-year increase in age. Crossover to IV sedation was associated with greater rates of adverse events, ED length of stay, and quantity of opioids received compared to either IAL or IV sedation alone.

Conclusions

Participants with unplanned IV sedation after IAL had more adverse events than those who received either method alone. Older age was associated with unplanned sedation after IAL. Prospective studies are needed to further define patient factors likely to contribute to failure of IAL.

Background

Acute rhinosinusitis is frequently diagnosed in emergency departments and primary care settings across the United States. Most cases are allergic or viral in etiology and resolve with supportive measures. Complications are rare, but when occurring are typically a result of bacterial sinusitis, extension of infection, and cerebral venous thrombosis. We describe a case of acute rhinosinusitis with co-existing acute angle closure glaucoma.

Case report

A 42-year-old female with history of headache disorder presented to the emergency department with the chief complaint of a left-sided headache, blurry vision, aural fullness, malaise and fatigue. She was suspected to have a viral syndrome with associated headache of non-emergent etiology and was discharged after partial improvement in response to a conventional analgesic regimen. She returned with worsening symptoms and was subsequently discovered to have acute angle closure glaucoma (AACG) by tonometry and sinusitis by Computed Tomography. The patient's intraocular pressures improved with standard AACG therapies. She was continued on these medications at discharge in combination with amoxicillin for presumed bacterial sinusitis.

Why should an emergency physician be aware of this?

Sinusitis and AACG have overlapping symptoms and can co-occur. Thus, AACG should be considered in a patient that presents with symptoms suggestive of sinusitis with an associated ocular complaint. Further study should seek to measure the relationship between these two diseases and investigate potential causal links.

Categories

Emergency Medicine, Ophthalmology, Otolaryngology.

Keywords

Case report, Sinusitis, Glaucoma, Acute angle closure glaucoma, Blurry vision.

Disclaimer

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Background

Acute respiratory illness remains a worldwide leading cause of morbidity and mortality.

Objective

This study was undertaken to identify trends in Respiratory Virus Panel (RVP) use and diagnostic results from 2019 to 2022.

Methods

The institutional Medical Laboratory created a database that included all RVP test results. The database included month and year of test, RVP test results, subject age, and sex.

Results

Utilization of RVP testing markedly expanded from 2019, with a mean utilization of 2 tests per quarter, to 2022, with a mean utilization of 1071 tests per quarter. Diagnostic results varied over time. The incidence of multiple pathogens per test increased from 2019 to 2022, although the percentage of tests with multiple pathogens did not differ significantly. The incidence of specific virus results varied by time. Adenovirus, COVID-19, Influenza A, Metapneumovirus, parainfluenza, and RSV were found more commonly in 2021 and 2022 compared to 2019 and 2020.

Conclusions

Utilization of RVP testing markedly expanded from 2019. Adenovirus, COVID-19, Influenza A, Metapneumovirus, parainfluenza, and RSV were found more commonly in 2021 and 2022 compared to 2019 and 2020.

Background

Ear piercings are a common practice for body modification and self-expression, but they can lead to various complications, including embedded jewelry, infections, and difficulty removing earring backings. Traditional techniques for removing stuck backings involve forceful manipulation, resulting in pain, scarring, and suboptimal cosmetic outcomes.

Discussion

In this technique description, we present an alternative atraumatic technique for the removal of stuck ear-piercing backings. The technique involves injecting a mixture of local anesthetic and a vasoconstrictor, around the backing to create a fluid pocket that loosens the earring post. A special maneuver is then applied using a needle driver allowing for easy gentle removal. If the backing remains embedded, gentle pressure on the earlobe reveals a loop that can be threaded with a syringe needle to propel the backing out.

Conclusions

The proposed atraumatic technique for removing stuck ear-piercing backings offers a satisfactory and less stressful experience for pediatric patients while reducing the need for emergency department referrals. Given the lack of consensus on extraction methods, this technique provides a valuable alternative in the absence of a widely agreed-upon approach. Further research is needed to establish standardized protocols. Nevertheless, adopting this technique has the potential to enhance patient satisfaction and improve outcomes.

Closed avulsion injuries of the flexor digitorum profundus (FDP) from the insertion at the base of the distal phalanx are not a very common lesion but when they occur, tend to be related to sport injuries. Though the diagnosis is made clinically, radiographs need be performed. Prompt surgical treatment within 7 to 14 days is the first line option to assure good outcomes.

Background: Volvulus of the large intestine is a relatively uncommon cause of bowel obstruction. A rare complication is abdominal compartment syndrome, which can manifest as multisystem organ failure. Case Report: We present a case of a 62-year-old hemiparetic man who presented intubated for respiratory distress, and later became unstable, with profound hypotension and hypoxia. He was found to have a large sigmoid volvulus causing acute abdominal compartment syndrome with compression of bilateral lower lungs and mediastinal structures, and ultimately survived to undergo an exploratory laparotomy with sigmoidectomy. Why should an emergency physician be aware of this? Respiratory distress and abdominal pain are some of the most common chief complaints presenting to the ED. Emergency physicians must be aware of the potential sequelae of bowel obstruction, and recall that not all respiratory failure is caused by a primary cardiopulmonary process.

Background

Upper back pain is a common occurrence with a lifetime prevalence of up to 19%. Patients with refractory upper back pain can pose a unique challenge to the emergency physician. The use of ultrasound-guided regional anesthesia is an important component of multi-modal analgesia in the emergency department. Ultrasound-guided peripheral nerve hydrodissection has been shown to be an effective treatment of various nerve entrapment syndromes in the outpatient setting.

Case report

We present 2 cases of patients who presented to the emergency department with refractory upper back pain failing standard therapy who were treated successfully using an ultrasound-guided combined 2–in-1 hydrodissection of the spinal accessory nerve and dorsal scapular nerve.

Why should an emergency physician be aware of this?

This technique may offer a safe, rapid, and effective approach to treating patients with refractory upper back pain. Further studies would be required to assess its utility on a broader scale.

Background

Accelerated diagnostic protocols (ADPs) that incorporate high-sensitivity cardiac troponin (hs-cTn) can help emergency department (ED) providers quickly rule in or out acute myocardial infarction (AMI).

Objectives

This systematic review evaluated the effectiveness and comparative effectiveness of clinically applied ADPs that use hs-cTn on clinical and health service use outcomes.

Methods

Medline, Embase, ClinicalTrials.gov, and the Cochrane Database of Systematic Reviews were searched through May 2022. Standard systematic review methods were followed.

Results

We found 17 eligible primary studies (reporting on 23 ADPs), including 2 randomized controlled trials (N ​= ​32,050), 5 nonrandomized comparative studies (N ​= ​18,377) and 10 single-group studies (N ​= ​44,016). One study compared an ADP with hs-cTn to hs-cTn alone, finding that the ADP increased discharges from the ED to the community and is not associated with worse clinical outcomes. Among 6 studies, ADPs with shorter compared to longer hs-cTn timing and ADPs that incorporated the HEART score compared to the TIMI score reduced ED length of stay and increased discharges to the community without resulting in worse clinical outcomes. Across studies, ADPs that measured hs-cTn for up to 12 ​h had longer ED lengths of stay than ADPs with ≤6 ​h of measurements.

Conclusions

ADPs with shorter compared to longer hs-cTn timing reduce ED length of stay, increase discharges, and are not associated with changes in 30-day major adverse cardiovascular event, AMI, or mortality. Among ADPs that reduce ED length of stay, there is no obvious best choice, and any ADP should be tailored to local context.

Background

The United States is experiencing a mental health (MH) crisis with limited resources to meet demands. We established a 5-bed psychiatric overflow unit (POU) within the emergency department (ED) as a care alternative.

Objective

Determine the clinical utility and safety of a POU in care delivery to patients in a MH crisis compared to the main ED (controls).

Methods

Retrospective study using data from electronic health record/chart review [October 1, 2021–May 31, 2022 (POU established January 2022)] for all ED patients ≥12 years admitted with MH crisis. Per triage nurse, patients for potential hospital admission were POU admitted when medically cleared. Clinical utility definition: ED length of stay (LOS); patient safety definition: return to ED within 72 ​h for same complaint.

Results

Patients (n ​= ​919; POU ​= ​302, main ED ​= ​617) were 61.4% male, mean age 39.7 ​± ​15.6 years, 84.2% ESI 2, 61.7% admitted/transferred, average ED LOS was 932.3 ​± ​804.7 ​min and no returns within 72 ​h. POU had longer ED LOS (1058.7 ​± ​736.5 vs 884.6 ​± ​824.6, P ​< ​0.0001) but no differences among admitted/transferred patients comparing POU vs controls (P ​> ​0.05); Among discharged patients POU compared to main ED had a longer mean ED LOS (819.9 ​± ​779.8 vs 486.4 ​± ​577.3, P ​< ​0.0001); Removal of police escort patients did not change POU ED LOS (P ​< ​0.05).

Conclusions

An ED POU, staffed with behavioral health nurses, had equivocal safety and clinical utility as the main ED potentially providing an alternative care-delivery option when ED space and MH resources are limited.