JEM reports最新文献

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.

Background

Prostate abscess differs from prostatitis as a complicated infection requiring appropriate early treatment. It typically presents with urinary symptoms plus rectal or pelvic pain in middle-aged or older men. Diabetic, immunosuppressed, or patients with urological procedures are at higher risk for serious infection. If untreated, prostate abscess can progress to critical illness including sepsis and death, thus early diagnosis and treatment is key.

Case report

A middle-aged male with diabetes, hypertension, emphysema, and hypothyroidism presented with severe constipation for one week but no urinary symptoms, fever, or vomiting. On examination, he had mild abdominal distension without tenderness, decreased bowel sounds, and a normal external rectal exam. Computed tomography scan demonstrated prostatomegaly and a large 5.2cm prostate abscess with multiple lobulations causing mass effect on the distal colon, thus blood cultures were sent, intravenous antibiotics started, and urology consulted. The patient was admitted for continued antibiotic treatment and underwent surgical transurethral resection with urology the next day. A foley catheter was maintained for seven days, with improvement until hospital discharge 3 days later, with oral antibiotics and close urology clinic follow up.

Why should an emergency medicine physician be aware of this?

Prostate abscess is difficult to diagnose clinically and can lead to severe illness without early recognition and treatment. Patients may present with pelvic or rectal pain plus fever or urinary symptoms. Urgent antibiotic therapy is key, and many patients require urology consultation for surgical or procedural management.

Background

Eczema Herpeticum (EH) is a dermatological emergency that may progress to viral meningitis in patients not treated urgently. We present a case of recurrent EH in a young, immunocompetent patient complicated by progressing herpetic meningitis and staphylococcal bacteremia.

Case report

Our patient was a 20-year-old male intercollegiate athlete with a past medical history of atopic dermatitis (AD) who presented with photophobia, purulence in the medial left eye, and a painful rapidly worsening acute rash for two days. Polymerase chain reaction was performed on the cerebrospinal fluid and vesicular drainage. Both tested positive for herpes simplex virus type 1 (HSV-1), confirming the suspected diagnosis of EH. Blood culture returned positive for Staphylococcus aureus believed to be contracted through the breaks in his skin. He received intravenous normal saline, ceftriaxone, and acyclovir. He was hospitalized for 9 days before being discharged with oral acyclovir. Our patient returned to the emergency department one month later with a milder case of EH. Intravenous acyclovir was started, and the patient was discharged the next day with 1 g oral valacyclovir twice daily.

Why should an emergency physician be aware of this?

It is crucial to establish a previous history of HSV-1 infection and recognize cutaneous presentations of EH in order to initiate early empiric antiviral therapy. The emergency physician must be hypervigilant and aggressively pursue diagnosis and treatment of suspected HSV-1 and -2 infections when confronted with an inexplicably worsening vesicular rash in a patient with AD. Delay in treatment can significantly worsen prognosis and lead to mortality.

Background

Pleural effusions are common problems for the emergency medicine physician and may require emergent therapeutic thoracentesis to prevent respiratory failure. Rarely, a pleural fluid collection may in fact be a spontaneous hemothorax.

Case report

A 22-year-old man presented to the emergency department with chest pain. He had a history of end-stage renal disease (ESRD) as a result of minimal change disease. The patient was in visible respiratory distress with absent breath sounds in the right chest. A chest x-ray revealed a large pleural effusion with mediastinal shift. Emergent thoracentesis relieved the patient’s symptoms, but the pleural fluid was grossly bloody. The patient’s cell counts and PT/PTT were normal. His thromboelastography (TEG) was borderline abnormal. The patient required video-assisted thoracoscopic surgery (VATS) for debulking and removal of the hemothorax. Otherwise, he had an unremarkable recovery. There was no obvious cause of the hemothorax. Clinicians must be wary that in patients with ESRD on hemodialysis, a pleural effusion may be in fact a spontaneous hemothorax. Why should an emergency medicine physician be aware of this? Patients with ESRD may present with massive spontaneous hemothorax that requires emergent thoracostomy and operative management. Emergency medicine physicians should be knowledgeable about the causes and work-up of patients with spontaneous hemothorax.

Background

Nerve hydrodissection (HD) has previously been described as a treatment for carpal tunnel syndrome and other musculoskeletal disorders; however, its use in the treatment of occipital neuralgia (ON) has rarely been reported. This is the first report of HD used to treat ON in the emergency department (ED).

Case report

A 34-year-old male presented to the ED with a 3-month history of posterior neck and scalp pain consistent with ON. He failed multiple outpatient therapies including oral medication and trigger point injections. An ultrasound (US)-guided HD of the greater occipital nerve (GON) was performed successfully. A 25 g needle was inserted in-plane and a solution of 9 mL normal saline and 1 mL 1 ​% lidocaine was injected within the fascial plane containing the GON until muscle layer separation was achieved.

Why should an emergency physician be aware of this? A case of refractory ON failing conventional therapy was successfully treated in the ED using US-guided nerve HD.

Background

Foreign body (FB) ingestion is a common presentation in the emergency department (ED). Point-of-care ultrasound (PoCUS) is useful for detecting ingested foreign bodies in pediatrics. However, its utility for diagnosing FB ingestions in adult patients has not been well described.

Case report

We present a case of a 52-year-old female patient who presented to our ED with right upper abdominal pain. A PoCUS revealed a long echogenic structure between the gastric pylorus and the gallbladder wall. The appearance raised suspicion for a foreign body perforating through the gastric wall. A CT scan confirmed the diagnosis of a fishbone perforating through the gastric wall. The patient underwent exploratory laparoscopic surgery that confirmed the perforation. The fishbone was removed endoscopically, and the patient made an unremarkable recovery.

Why should an emergency physician be aware of this?

Foreign body ingestion is an important cause of abdominal pain in the ED and can lead to significant morbidity if there is a delay in diagnosis. Some patients may not be aware that they ingested a foreign body. Identification of an abnormal echogenic structure in the abdomen at the site of tenderness should prompt further investigation and consultation.

Background

Bacterial pericarditis is a rare cause of pericardial disease, with purulent pericarditis making up less than 1 ​% of bacterial cases worldwide.

Case report

We report the case of a 52-year-old male with diabetes and end-stage renal disease on dialysis who presented for chest pain with an electrocardiogram concerning for myocardial ischemia. He was found to have a large pericardial effusion with heterogenous material and signs of sonographic tamponade on bedside ultrasound. His vital signs did not have any fever, tachycardia, or hypotension. His physical examination was negative for diminished heart sounds or jugular venous distension. He underwent a pericardiocentesis that grew staphylococcus aureus and was found to have a mediastinal abscess that required excision.

“Why should an emergency physician be aware of this?”

Bedside point-of-care transthoracic echocardiography can diagnose purulent pericarditis in the absence of clinical examination findings, electrocardiogram changes, or vital sign abnormalities.