Pub Date : 2025-04-11DOI: 10.1016/j.jemrpt.2025.100167
Jonathan Mohnkern , Laura Williams , Christopher Fullagar
Background
Pediatric patients with sustained tachyarrhythmias present unique challenges to prehospital clinicians due to differences in physiology, pathology, compensatory mechanisms, and treatment algorithms. Additionally, pediatric patients require careful thought into the psychosocial impacts that one's demeanor, treatment, and explanations will have on them.
Case report
This case illustrates an adolescent male with a history of Chiari 1 malformation who presented to EMS with sustained monomorphic ventricular tachycardia (VT). An unusual rhythm response was experienced during electrical cardioversion, where this intervention resulted in an immediate doubling of his heart rate.
Why should an emergency physician be aware of this?
We discuss approaches to pediatric dysrhythmias, differential diagnosis considerations, appropriate management of wide-complex tachycardia, and methods to reduce the psychological burden on patients and families in a first-encounter clinical situation.
{"title":"Wide-complex tachycardia with an unusual response to electrical cardioversion in an adolescent with Chiari 1 malformation: A case report","authors":"Jonathan Mohnkern , Laura Williams , Christopher Fullagar","doi":"10.1016/j.jemrpt.2025.100167","DOIUrl":"10.1016/j.jemrpt.2025.100167","url":null,"abstract":"<div><h3>Background</h3><div>Pediatric patients with sustained tachyarrhythmias present unique challenges to prehospital clinicians due to differences in physiology, pathology, compensatory mechanisms, and treatment algorithms. Additionally, pediatric patients require careful thought into the psychosocial impacts that one's demeanor, treatment, and explanations will have on them.</div></div><div><h3>Case report</h3><div>This case illustrates an adolescent male with a history of Chiari 1 malformation who presented to EMS with sustained monomorphic ventricular tachycardia (VT). An unusual rhythm response was experienced during electrical cardioversion, where this intervention resulted in an immediate doubling of his heart rate.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>We discuss approaches to pediatric dysrhythmias, differential diagnosis considerations, appropriate management of wide-complex tachycardia, and methods to reduce the psychological burden on patients and families in a first-encounter clinical situation.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100167"},"PeriodicalIF":0.0,"publicationDate":"2025-04-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143837826","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-04-02DOI: 10.1016/j.jemrpt.2025.100166
Evan Lawyer , Jessica Krizo , Kailee Pollock , Carline Mangira , Erin L. Simon
Background
Ondansetron, an anti-emetic with the potential to cause QT-prolongation and dysrhythmia, is commonly used in the emergency department. It is unclear how often ondansetron is given to patients with prolonged QT intervals and if these patients are more likely to have dysrhythmias.
Objectives
We determined the frequency of the use of ondansetron in patients with a corrected QT (QTc) interval ≥500 ms and the rate of dysrhythmias in this population.
Methods
This study was a retrospective review of adult patients who presented to one of 17 EDs within a large integrated healthcare system between May 1, 2021, and April 30, 2023. Patients were included if they had an electrocardiogram (ECG) and received ondansetron. Patients were categorized by QTc length. Categorical variables were described using frequencies and percentages and p-values obtained from Pearson Chi square or Fisher's exact tests where appropriate.
Results
A total of 42,530 patients were included. Of these, 56 developed dysrhythmias. Patients administered ondansetron with a measured QTc ≥500 (n = 2302), compared to patients with a measured QTc <500 (n = 40,228), were not at increased risk for developing a dysrhythmia (p = 1.000). A total of 11 patients with a QTc >475 (n = 6572), developed a dysrhythmia and there was an increased incidence of supraventricular tachycardia (p = 0.002) and cardiac arrest (p = 0.002).
Conclusion
This study shows that most patients (95 %) who had an ECG and were administered ondansetron have a QTc <500. The incidence of dysrhythmia in patients with a QTc >500 was 0.09 % and in those with a QTc >475 was 0.17 %.
{"title":"QTc prolongation and dysrhythmia risk in emergency department patients administered ondansetron","authors":"Evan Lawyer , Jessica Krizo , Kailee Pollock , Carline Mangira , Erin L. Simon","doi":"10.1016/j.jemrpt.2025.100166","DOIUrl":"10.1016/j.jemrpt.2025.100166","url":null,"abstract":"<div><h3>Background</h3><div>Ondansetron, an anti-emetic with the potential to cause QT-prolongation and dysrhythmia, is commonly used in the emergency department. It is unclear how often ondansetron is given to patients with prolonged QT intervals and if these patients are more likely to have dysrhythmias.</div></div><div><h3>Objectives</h3><div>We determined the frequency of the use of ondansetron in patients with a corrected QT (QTc) interval ≥500 ms and the rate of dysrhythmias in this population.</div></div><div><h3>Methods</h3><div>This study was a retrospective review of adult patients who presented to one of 17 EDs within a large integrated healthcare system between May 1, 2021, and April 30, 2023. Patients were included if they had an electrocardiogram (ECG) and received ondansetron. Patients were categorized by QTc length. Categorical variables were described using frequencies and percentages and p-values obtained from Pearson Chi square or Fisher's exact tests where appropriate.</div></div><div><h3>Results</h3><div>A total of 42,530 patients were included. Of these, 56 developed dysrhythmias. Patients administered ondansetron with a measured QTc ≥500 (n = 2302), compared to patients with a measured QTc <500 (n = 40,228), were not at increased risk for developing a dysrhythmia (p = 1.000). A total of 11 patients with a QTc >475 (n = 6572), developed a dysrhythmia and there was an increased incidence of supraventricular tachycardia (p = 0.002) and cardiac arrest (p = 0.002).</div></div><div><h3>Conclusion</h3><div>This study shows that most patients (95 %) who had an ECG and were administered ondansetron have a QTc <500. The incidence of dysrhythmia in patients with a QTc >500 was 0.09 % and in those with a QTc >475 was 0.17 %.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100166"},"PeriodicalIF":0.0,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143820313","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-22DOI: 10.1016/j.jemrpt.2025.100164
Joseph R. Brown , Michael Heffler , Peter Alsharif , Brigit Noon , Justin Inman , Eric Bustos , Juliana Wilson , Ryan Tucker
Background
Ultrasound-guided nerve blocks (UGNBs) are a vital component of a multimodal approach to managing pain in the Emergency Department (ED). However, implementation has not been universally adopted due to their time-consuming nature and provider discomfort with the procedure.
Objectives
The primary outcome of this study was to deploy a new UGNB cart and group of nerve block “champions” and evaluate whether the rate of infrainguinal fascia iliaca compartment block (IFICB) use increased in geriatric hip fractures. Secondary outcomes included length of stay in the ED, complications associated with the UGNB and Morphine Equivalents used compared to patients who did not receive the IFICB.
Methods
This was a prospective, observational cohort study performed at a single urban, academic site. Inclusion criteria was based on institutional coding of a hip fracture. Each chart was reviewed as to whether the patient received an IFICIB as well as secondary outcomes like ED length of stay (LOS). Finally, the treating physician was surveyed regarding their decision to perform an IFICB.
Results
Of the 146 eligible patients, 15.8 % received an IFICB, an increase from 2.6 % in 2019. 55 physicians were enrolled with a 96 % response rate. Commonly cited reasons for not performing the block were controlled pain and lack of training. Of the 23 UGNBs performed, 14 involved a champion. Despite length of time being cited 10.6 % of the time for not performing the IFICB, patients who received a IFICB had a shorter ED LOS.
Conclusion
This study showed that the creation of nerve block “champions” and implementation of an UGNB cart was associated with an increase in their utilization of the IFICB.
{"title":"A nerve block supply cart and nerve block champions program associated with increased fascia iliaca block use","authors":"Joseph R. Brown , Michael Heffler , Peter Alsharif , Brigit Noon , Justin Inman , Eric Bustos , Juliana Wilson , Ryan Tucker","doi":"10.1016/j.jemrpt.2025.100164","DOIUrl":"10.1016/j.jemrpt.2025.100164","url":null,"abstract":"<div><h3>Background</h3><div>Ultrasound-guided nerve blocks (UGNBs) are a vital component of a multimodal approach to managing pain in the Emergency Department (ED). However, implementation has not been universally adopted due to their time-consuming nature and provider discomfort with the procedure.</div></div><div><h3>Objectives</h3><div>The primary outcome of this study was to deploy a new UGNB cart and group of nerve block “champions” and evaluate whether the rate of infrainguinal fascia iliaca compartment block (IFICB) use increased in geriatric hip fractures. Secondary outcomes included length of stay in the ED, complications associated with the UGNB and Morphine Equivalents used compared to patients who did not receive the IFICB.</div></div><div><h3>Methods</h3><div>This was a prospective, observational cohort study performed at a single urban, academic site. Inclusion criteria was based on institutional coding of a hip fracture. Each chart was reviewed as to whether the patient received an IFICIB as well as secondary outcomes like ED length of stay (LOS). Finally, the treating physician was surveyed regarding their decision to perform an IFICB.</div></div><div><h3>Results</h3><div>Of the 146 eligible patients, 15.8 % received an IFICB, an increase from 2.6 % in 2019. 55 physicians were enrolled with a 96 % response rate. Commonly cited reasons for not performing the block were controlled pain and lack of training. Of the 23 UGNBs performed, 14 involved a champion. Despite length of time being cited 10.6 % of the time for not performing the IFICB, patients who received a IFICB had a shorter ED LOS.</div></div><div><h3>Conclusion</h3><div>This study showed that the creation of nerve block “champions” and implementation of an UGNB cart was associated with an increase in their utilization of the IFICB.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100164"},"PeriodicalIF":0.0,"publicationDate":"2025-03-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143697662","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-21DOI: 10.1016/j.jemrpt.2025.100165
Ariella Gartenberg , Capwell Taylor , Arvind Haran , Alexander Petrie
Background
Systemic sclerosis is a rare and chronic autoimmune connective tissue disease that involves widespread vascular dysfunction, as well as fibrosis of the skin and internal organs. With the development of organ-based treatment, including ACE-inhibitors for renal crisis and goal directed therapy for heart failure, the mortality associated with renal and cardiac involvement has decreased significantly. Consequently, the increased risk of malignancy in patients with systemic sclerosis has become a topic of concern. Once the diagnosis of systemic sclerosis is made, various associated disease processes, including malignancy, must be screened for.
Case report
This case report details a 44 year old female presenting to the Emergency Department with abdominal pain, vaginal bleeding, pruritic rash, and two syncopal episodes. The patient was ultimately diagnosed with systemic sclerosis with extensive “salt and pepper” skin pigmentation and tightening over the arms, chest, and back, with associated bilateral breast masses, an adrenal lesion, liver mass, and endometrial squamous metaplasia.
Why should an emergency physician be aware of this? A chief complaint as common as “syncope” can be an atypical presentation of less common, difficult to diagnose conditions in the emergency department, such as systemic sclerosis. While systemic sclerosis is not a diagnosis readily made in the emergency department, prompt recognition and appropriate consulting services or referrals can prevent long-term devastating complications and associated morbidity and mortality.
{"title":"Systemic sclerosis with associated endometrial squamous metaplasia, liver mass, adrenal lesion and bilateral breast masses: Case report","authors":"Ariella Gartenberg , Capwell Taylor , Arvind Haran , Alexander Petrie","doi":"10.1016/j.jemrpt.2025.100165","DOIUrl":"10.1016/j.jemrpt.2025.100165","url":null,"abstract":"<div><h3>Background</h3><div>Systemic sclerosis is a rare and chronic autoimmune connective tissue disease that involves widespread vascular dysfunction, as well as fibrosis of the skin and internal organs. With the development of organ-based treatment, including ACE-inhibitors for renal crisis and goal directed therapy for heart failure, the mortality associated with renal and cardiac involvement has decreased significantly. Consequently, the increased risk of malignancy in patients with systemic sclerosis has become a topic of concern. Once the diagnosis of systemic sclerosis is made, various associated disease processes, including malignancy, must be screened for.</div></div><div><h3>Case report</h3><div>This case report details a 44 year old female presenting to the Emergency Department with abdominal pain, vaginal bleeding, pruritic rash, and two syncopal episodes. The patient was ultimately diagnosed with systemic sclerosis with extensive “salt and pepper” skin pigmentation and tightening over the arms, chest, and back, with associated bilateral breast masses, an adrenal lesion, liver mass, and endometrial squamous metaplasia.</div><div><strong>Why should an emergency physician be aware of this?</strong> A chief complaint as common as “syncope” can be an atypical presentation of less common, difficult to diagnose conditions in the emergency department, such as systemic sclerosis. While systemic sclerosis is not a diagnosis readily made in the emergency department, prompt recognition and appropriate consulting services or referrals can prevent long-term devastating complications and associated morbidity and mortality.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100165"},"PeriodicalIF":0.0,"publicationDate":"2025-03-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143683254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-20DOI: 10.1016/j.jemrpt.2025.100163
Christine E. Maloney, William B. Prince
Background
Pruritus is a common complaint seen by emergency medicine physicians and carries a broad differential encompassing dermatologic, systemic, neurologic, and psychogenic etiologies.
Case report
A 16-year-old girl presented to the emergency department with two months of pruritus and rash. Prior diagnoses for her symptoms included atopic dermatitis, medication-induced tactile hallucinations, and scabies. Physical examination in the emergency department was notable for a firm supraclavicular lymph node and laboratory studies were notable for systemic inflammation. Biopsy revealed a new diagnosis of classical Hodgkin lymphoma.
Why should an emergency physician be aware of this?
Recognition of refractory chronic pruritus by frontline providers as a presenting symptom of Hodgkin lymphoma can prevent diagnostic delay.
{"title":"When itching signals more: A case of chronic pruritus leading to cancer diagnosis","authors":"Christine E. Maloney, William B. Prince","doi":"10.1016/j.jemrpt.2025.100163","DOIUrl":"10.1016/j.jemrpt.2025.100163","url":null,"abstract":"<div><h3>Background</h3><div>Pruritus is a common complaint seen by emergency medicine physicians and carries a broad differential encompassing dermatologic, systemic, neurologic, and psychogenic etiologies.</div></div><div><h3>Case report</h3><div>A 16-year-old girl presented to the emergency department with two months of pruritus and rash. Prior diagnoses for her symptoms included atopic dermatitis, medication-induced tactile hallucinations, and scabies. Physical examination in the emergency department was notable for a firm supraclavicular lymph node and laboratory studies were notable for systemic inflammation. Biopsy revealed a new diagnosis of classical Hodgkin lymphoma.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>Recognition of refractory chronic pruritus by frontline providers as a presenting symptom of Hodgkin lymphoma can prevent diagnostic delay.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100163"},"PeriodicalIF":0.0,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143683255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-20DOI: 10.1016/j.jemrpt.2025.100162
Nina C. Lund, Jennifer L. Hemberg
Background
Pseudoaneurysm represents an unusual cause of unilateral extremity pain in the acute care setting. However, a growing body of literature supports its inclusion in the standard differential for acute-onset extremity pain. Consideration for pseudoaneurysm is particularly justified in management of pediatric patients, who may bear undiagnosed syndromes conferring increased risk of vascular injury.
Case report
We present an unusual case of acute onset unilateral extremity pain in an otherwise healthy 17-year-old male resulting from spontaneous peroneal artery rupture with pseudoaneurysm identified on emergent angiography. In this case, pseudoaneurysm was complicated by compartment syndrome necessitating four compartment fasciotomy and washout with delayed closure.
Why should an emergency physician be aware of this?
Our discussion reviews current evidence for emergent vascular imaging in the pediatric population. If there is a high suspicion for pseudoaneurysm or other vascular emergency, providers should prioritize computed tomography with angiography over magnetic resonance. Prompt diagnosis is critical to avert progression to compartment syndrome and/or disability. We also discuss the known causes of pseudoaneurysm and conclude that the finding of spontaneous pseudoaneurysm should trigger evaluation for related genetic and rheumatologic disorders with the aim of mitigating morbidity and mortality related to the underlying disease process.
{"title":"Spontaneous peroneal pseudoaneurysm in the young athlete","authors":"Nina C. Lund, Jennifer L. Hemberg","doi":"10.1016/j.jemrpt.2025.100162","DOIUrl":"10.1016/j.jemrpt.2025.100162","url":null,"abstract":"<div><h3>Background</h3><div>Pseudoaneurysm represents an unusual cause of unilateral extremity pain in the acute care setting. However, a growing body of literature supports its inclusion in the standard differential for acute-onset extremity pain. Consideration for pseudoaneurysm is particularly justified in management of pediatric patients, who may bear undiagnosed syndromes conferring increased risk of vascular injury.</div></div><div><h3>Case report</h3><div>We present an unusual case of acute onset unilateral extremity pain in an otherwise healthy 17-year-old male resulting from spontaneous peroneal artery rupture with pseudoaneurysm identified on emergent angiography. In this case, pseudoaneurysm was complicated by compartment syndrome necessitating four compartment fasciotomy and washout with delayed closure.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>Our discussion reviews current evidence for emergent vascular imaging in the pediatric population. If there is a high suspicion for pseudoaneurysm or other vascular emergency, providers should prioritize computed tomography with angiography over magnetic resonance. Prompt diagnosis is critical to avert progression to compartment syndrome and/or disability. We also discuss the known causes of pseudoaneurysm and conclude that the finding of spontaneous pseudoaneurysm should trigger evaluation for related genetic and rheumatologic disorders with the aim of mitigating morbidity and mortality related to the underlying disease process.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100162"},"PeriodicalIF":0.0,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143704009","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-14DOI: 10.1016/j.jemrpt.2025.100161
Alexandra Over, Tyler Nghiem, Pamela Santivanez, Amin Mohamadi, Josh Greenstein, Barry Hahn, William Caputo
Background
Inferior glenohumeral dislocation (IGD), or luxatio erecta humeri, is a rare shoulder dislocation, accounting for 0.5 % of all cases. It often results from hyperabduction of the arm, causing the humeral head to dislocate inferiorly. IGD is associated with neurovascular complications, particularly in elderly patients with comorbidities. Traditional management involves procedural sedation, which may be risky in high-risk patients. Ultrasound-guided interscalene nerve blocks offer a safer alternative by providing localized pain control without sedation.
Case report
We report the case of an 85-year-old male with multiple comorbidities who presented with IGD after a fall. Given the patient's risks, an ultrasound-guided interscalene block was used for reduction. Reduction was achieved using the traction-countertraction method, confirmed by post-reduction radiographs. The patient experienced no immediate complications, and at follow-up, showed no signs of re-dislocation or neurological deficits.Why should an emergency physician be aware of this? Ultrasound-guided interscalene nerve blocks provide a safe and effective alternative to procedural sedation for IGD reduction, especially in high-risk patients. This approach minimizes opioid use, improves outcomes, and reduces emergency department resource utilization. Future guidelines should consider incorporating this technique for similar cases, with further studies needed to evaluate long-term outcomes.
{"title":"Ultrasound-guided interscalene block for the reduction of luxatio erecta in a high-risk patient: A case report","authors":"Alexandra Over, Tyler Nghiem, Pamela Santivanez, Amin Mohamadi, Josh Greenstein, Barry Hahn, William Caputo","doi":"10.1016/j.jemrpt.2025.100161","DOIUrl":"10.1016/j.jemrpt.2025.100161","url":null,"abstract":"<div><h3>Background</h3><div>Inferior glenohumeral dislocation (IGD), or luxatio erecta humeri, is a rare shoulder dislocation, accounting for 0.5 % of all cases. It often results from hyperabduction of the arm, causing the humeral head to dislocate inferiorly. IGD is associated with neurovascular complications, particularly in elderly patients with comorbidities. Traditional management involves procedural sedation, which may be risky in high-risk patients. Ultrasound-guided interscalene nerve blocks offer a safer alternative by providing localized pain control without sedation.</div></div><div><h3>Case report</h3><div>We report the case of an 85-year-old male with multiple comorbidities who presented with IGD after a fall. Given the patient's risks, an ultrasound-guided interscalene block was used for reduction. Reduction was achieved using the traction-countertraction method, confirmed by post-reduction radiographs. The patient experienced no immediate complications, and at follow-up, showed no signs of re-dislocation or neurological deficits.<strong>Why should an emergency physician be aware of this?</strong> Ultrasound-guided interscalene nerve blocks provide a safe and effective alternative to procedural sedation for IGD reduction, especially in high-risk patients. This approach minimizes opioid use, improves outcomes, and reduces emergency department resource utilization. Future guidelines should consider incorporating this technique for similar cases, with further studies needed to evaluate long-term outcomes.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100161"},"PeriodicalIF":0.0,"publicationDate":"2025-03-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143643457","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gastric ultrasound is mainly used in the preoperative evaluation of patients for aspiration risk assessment. This is accomplished by assessing the gastric antrum, which can be used to calculate the total gastric volume (TGV). We extrapolated this concept to our emergency department to manage cardiogenic pulmonary edema.
Case report
Here, we report a case of a 65-year-old man with comorbidities, namely, hypertension and coronary artery disease, who presented to the emergency department with acute cardiogenic pulmonary edema (ACPE) and had a drop in sensorium after a few minutes of hospital arrival, for whom we resorted to gastric ultrasound-guided noninvasive ventilation (G-NIV) under a sedation cover rather than intubation. We achieved excellent outcomes, and the patient was discharged healthy.
Why should an emergency physician be aware of this?
Although noninvasive ventilation (NIV) is a class 1 indication for ACPE, its role may be limited in altered sensorium or irritable patients. Ideally, these patients should be intubated and mechanically ventilated. However, in resource-limited settings where ventilators are not available, G-NIVs can be used. However, another advantage of G-NIV is that intubation-related complications can be avoided, resulting in early discharge and less morbidity.
{"title":"Gastric ultrasound-guided noninvasive ventilation for altered hypertensive cardiogenic pulmonary edema: A case report","authors":"Sasikumar Mahalingam , Gunaseelan Rajendran , Anitha Ramkumar , Kumaresh Pillur Tamilarasu , Aswin Kumaran , Surendar Ravipragasam , Tharun kumar Ganesan , Shivakumar Somannavar , Vijayalakshmi Padmanaban , Vinay Yareshimi , Nedurumalli Naga Vaishnavi , Nirmala Subbamanda Dinesh","doi":"10.1016/j.jemrpt.2025.100157","DOIUrl":"10.1016/j.jemrpt.2025.100157","url":null,"abstract":"<div><h3>Background</h3><div>Gastric ultrasound is mainly used in the preoperative evaluation of patients for aspiration risk assessment. This is accomplished by assessing the gastric antrum, which can be used to calculate the total gastric volume (TGV). We extrapolated this concept to our emergency department to manage cardiogenic pulmonary edema.</div></div><div><h3>Case report</h3><div>Here, we report a case of a 65-year-old man with comorbidities, namely, hypertension and coronary artery disease, who presented to the emergency department with acute cardiogenic pulmonary edema (ACPE) and had a drop in sensorium after a few minutes of hospital arrival, for whom we resorted to gastric ultrasound-guided noninvasive ventilation (G-NIV) under a sedation cover rather than intubation. We achieved excellent outcomes, and the patient was discharged healthy.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>Although noninvasive ventilation (NIV) is a class 1 indication for ACPE, its role may be limited in altered sensorium or irritable patients. Ideally, these patients should be intubated and mechanically ventilated. However, in resource-limited settings where ventilators are not available, G-NIVs can be used. However, another advantage of G-NIV is that intubation-related complications can be avoided, resulting in early discharge and less morbidity.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100157"},"PeriodicalIF":0.0,"publicationDate":"2025-03-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143579876","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The conventional clinical assessment of pupils & pupillometers has shown very poor interrater reliability. As a promising alternative, bedside ultrasound has emerged for pupillary assessment.
Objectives
Thus, we conducted a systematic review to assess ultrasound's utility and comparative effectiveness in pupillary assessment.
Methods
This systematic review involved searching three major databases—PubMed, Embase, and Scopus—from inception to April 2024, using predefined search terms. Inclusion criteria comprised adult patients over 18 years undergoing ultrasound for pupillary assessment, with comparison against standard methods such as pupillometry or clinical examination. Screening and data extraction were independently conducted by two investigators (GR, SM), with data appraisal utilizing the QUADAS-2 Risk of Bias assessment tool (CRD42024540402).
Results
Among 556 identified studies, seven met inclusion criteria, encompassing 865 patients and 1141 ultrasonographic pupillary assessments. Six of these studies reported a favourable correlation or association between ultrasound and pupillometer or clinical examination. Significant findings included a substantial correlation between ultrasound and infrared video pupillometry by Farina et al. (R = 0.831, p < 0.01), by Fu et al. (Bland-Altman agreement −0.069) & Modi et al. (Interclass Correlation Coefficient = 0.93). Diagnostic accuracy for identifying Relative Afferent Pupillary Defect (RAPD) had high sensitivity and specificity reported by Ramamoorthy et al. and Schmidt et al.
Conclusion
Our systematic review demonstrates a significant correlation/association between ultrasound and pupillometer or clinical examination for pupillary assessment. However, current evidence remains limited, and further high-quality research is needed before recommending routine use or claiming superiority over pupillometry or standard clinical assessments.
背景小学生的常规临床评估；瞳孔计显示出非常差的互传可靠性。作为一种有希望的替代方法，床边超声已经出现在瞳孔评估中。因此，我们进行了一项系统的综述，以评估超声在瞳孔评估中的效用和比较有效性。方法系统检索pubmed、Embase和scopus三个主要数据库，检索时间从数据库建立到2024年4月。纳入标准包括18岁以上接受超声瞳孔评估的成年患者，并与标准方法（如瞳孔测量或临床检查）进行比较。筛选和数据提取由两名研究者（GR， SM）独立进行，数据评估使用QUADAS-2偏倚风险评估工具（CRD42024540402）。结果在556项研究中，有7项符合纳入标准，包括865例患者和1141例超声瞳孔评估。其中六项研究报告了超声与瞳孔计或临床检查之间的良好相关性或相关性。Farina等人的重要发现包括超声和红外视频瞳孔测量之间存在显著相关性(R = 0.831, p <；0.01)，由Fu等人（Bland-Altman协议−0.069）&；Modi等（类间相关系数= 0.93）。Ramamoorthy等和Schmidt等报道，相对传入瞳孔缺损（Relative aff传入Pupillary Defect， RAPD）的诊断准确性具有很高的敏感性和特异性。结论我们的系统综述表明，超声与瞳孔计或临床检查在瞳孔评估方面具有显著的相关性。然而，目前的证据仍然有限，在推荐常规使用或声称优于瞳孔测量或标准临床评估之前，需要进一步的高质量研究。
{"title":"Ultrasound for Pupillary Assessment - A Systematic Review","authors":"Gunaseelan Rajendran , Sasikumar Mahalingam , Anitha Ramkumar , Yuvaraj Krishnamoorthy , P.T. Kumaresh , Vijayanthi Vijayan , Rajkumar Elanjaeran , Rahini Kannan , Sathya Prakasam , Anas Salih","doi":"10.1016/j.jemrpt.2025.100158","DOIUrl":"10.1016/j.jemrpt.2025.100158","url":null,"abstract":"<div><h3>Background</h3><div>The conventional clinical assessment of pupils & pupillometers has shown very poor interrater reliability. As a promising alternative, bedside ultrasound has emerged for pupillary assessment.</div></div><div><h3>Objectives</h3><div>Thus, we conducted a systematic review to assess ultrasound's utility and comparative effectiveness in pupillary assessment.</div></div><div><h3>Methods</h3><div>This systematic review involved searching three major databases—PubMed, Embase, and Scopus—from inception to April 2024, using predefined search terms. Inclusion criteria comprised adult patients over 18 years undergoing ultrasound for pupillary assessment, with comparison against standard methods such as pupillometry or clinical examination. Screening and data extraction were independently conducted by two investigators (GR, SM), with data appraisal utilizing the QUADAS-2 Risk of Bias assessment tool (CRD42024540402).</div></div><div><h3>Results</h3><div>Among 556 identified studies, seven met inclusion criteria, encompassing 865 patients and 1141 ultrasonographic pupillary assessments. Six of these studies reported a favourable correlation or association between ultrasound and pupillometer or clinical examination. Significant findings included a substantial correlation between ultrasound and infrared video pupillometry by Farina et al. (R = 0.831, p < 0.01), by Fu et al. (Bland-Altman agreement −0.069) & Modi et al. (Interclass Correlation Coefficient = 0.93). Diagnostic accuracy for identifying Relative Afferent Pupillary Defect (RAPD) had high sensitivity and specificity reported by Ramamoorthy et al. and Schmidt et al.</div></div><div><h3>Conclusion</h3><div>Our systematic review demonstrates a significant correlation/association between ultrasound and pupillometer or clinical examination for pupillary assessment. However, current evidence remains limited, and further high-quality research is needed before recommending routine use or claiming superiority over pupillometry or standard clinical assessments.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100158"},"PeriodicalIF":0.0,"publicationDate":"2025-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143551552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-28DOI: 10.1016/j.jemrpt.2025.100159
Ivana-Re Baldie, Beau Abar, Brenda Hernandez-Romero, Nancy Wood, Adrienne Morgan, David Adler
Background
Inadequate diversity among clinical trial participants threatens external validity. Potential explanations for disparities in participation include staff bias, lack of access to studies, and racial discordance between staff and patients.
Objectives
We examined associations between patient and enroller demographics and enrollment into a randomized controlled trial (RCT) on cancer screening among Emergency Department (ED) patients. Enrollment through the ED ensures access to trials across a diverse patient population, and the dataset analyzed is of sufficient magnitude and diversity (both in enrollers and patients) to provide novel evaluation.
Methods
Research enrollers identified potentially eligible ED patients for enrollment using the electronic health record, approached patients and described the RCT, and attempted to enroll them into the study.
Results
A total of 4419 patient-enroller encounters were documented. Enrollment rates were similar across enroller gender (47 % when enroller was a woman; 48 % when enroller was a man), though there was mild variability across enroller race (50 % when enroller was White; 45 % when enroller was Asian; 44 % when enroller was Black). Concordance between patient and enroller race was not tied to enrollment.
Conclusions
Conducting research in diverse settings like the ED can mitigate access barriers, as can enroller cultural competency training.
{"title":"Associations between enroller demographics and participant enrollment into an emergency department-based cancer prevention trial","authors":"Ivana-Re Baldie, Beau Abar, Brenda Hernandez-Romero, Nancy Wood, Adrienne Morgan, David Adler","doi":"10.1016/j.jemrpt.2025.100159","DOIUrl":"10.1016/j.jemrpt.2025.100159","url":null,"abstract":"<div><h3>Background</h3><div>Inadequate diversity among clinical trial participants threatens external validity. Potential explanations for disparities in participation include staff bias, lack of access to studies, and racial discordance between staff and patients.</div></div><div><h3>Objectives</h3><div>We examined associations between patient and enroller demographics and enrollment into a randomized controlled trial (RCT) on cancer screening among Emergency Department (ED) patients. Enrollment through the ED ensures access to trials across a diverse patient population, and the dataset analyzed is of sufficient magnitude and diversity (both in enrollers and patients) to provide novel evaluation.</div></div><div><h3>Methods</h3><div>Research enrollers identified potentially eligible ED patients for enrollment using the electronic health record, approached patients and described the RCT, and attempted to enroll them into the study.</div></div><div><h3>Results</h3><div>A total of 4419 patient-enroller encounters were documented. Enrollment rates were similar across enroller gender (47 % when enroller was a woman; 48 % when enroller was a man), though there was mild variability across enroller race (50 % when enroller was White; 45 % when enroller was Asian; 44 % when enroller was Black). Concordance between patient and enroller race was not tied to enrollment.</div></div><div><h3>Conclusions</h3><div>Conducting research in diverse settings like the ED can mitigate access barriers, as can enroller cultural competency training.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"4 2","pages":"Article 100159"},"PeriodicalIF":0.0,"publicationDate":"2025-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143551553","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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