JEM reports最新文献

Background

Carbon monoxide (CO) poisoning is associated with high morbidity and mortality. Diagnosis can be challenging for the encountering physician due to vague and nonspecific presenting signs and symptoms. Confirmatory testing is typically prompted by historical information identifying a key exposure or risk factor.

Case report

A patient presented to the emergency department after having a seizure. The patient was diagnosed with CO poisoning, with a carboxyhemoglobin level of >20.9 ​%, caused by unintentional exposure to motor vehicle exhaust while idling in his car after his catalytic converter was stolen. The patient was transferred to a hospital with the capacity for treatment with hyperbaric oxygen.

Why should an emergency physician be aware of this? Increasing prevalence of catalytic converter theft puts people at risk for CO poisoning. Emergency physicians should consider CO poisoning broadly, especially in urban environments with high rates of petty crime.

Background

The ultrasound guided popliteal sciatic block is a nerve block commonly used for pain control in the setting of distal tibia and/or fibular fractures, ankle reductions, Achilles tendon ruptures, and injuries to the lateral/posterior calf (burns, abscesses, or lacerations. In the Emergency Department, this block is classically performed by positioning the patient in a lateral or prone position. Unfortunately, in the acute setting, patient repositioning is often not possible secondary to pain, limiting the use of this block. In this case series, we describe a novel approach to the popliteal sciatic nerve block that allows the patient to remain in the supine position and enter from a crosswise approach.

Case report

This paper describes three cases, all which have painful complaints in the distribution of the popliteal sciatic nerve. In the first case, the patient has a bimalleolar ankle fracture. In the second, the patient has second degree burns that get contaminated and need decontamination. In the third, the patient has an unstable ankle fracture but will not accept opiates. In each, the presentation limits the provider’s ability to reposition the patient therefore this novel, crosswise approach to the popliteal sciatic nerve block allows optimal care without painful repositioning.

Why should an emergency physician be aware of this?

While further research is still needed on the crosswise approach to the popliteal sciatic nerve block, it offers a novel approach to this classic block without the need for patient repositioning.

Background

Hypokalemia is a common problem encountered in the emergency department. Severe cases of hypokalemia are associated with increased morbidity and mortality. ECG is an immediately-available test that can clinch the diagnosis, leading to immediate intervention. The trick is to differentiate ECG changes of severe hypokalemia from severe ischemia.

Case report

We here present a case of a middle-aged woman whose ECG showed sinus tachycardia with atrioventricular block, then supraventricular tachycardia with marked ischemic changes due to severe hypokalemia. Potassium level was 1.1 mEq/L. The ECG could have been mistaken for a high-risk, acute myocardial infarction due to severe left main and/or multi-vessel coronary artery disease. After initial potassium replenishment, classic text-book findings of hypokalemia became apparent. Troponin was mildly positive, however clinical presentation, the absence of chest pain, and confirmatory laboratory results led to the accurate decision not to activate a “Code STEMI” An echocardiogram done later showed no wall motion abnormalities. Supraventricular tachycardia terminated spontaneously. An ECG done after correction of hypokalemia was normal. No Q waves were noted.

Why should an emergency physician be aware of this?

Emergency department physicians, cardiologists, and internists, among other physicians should be aware of the recently-described pattern of diffuse ST segment depression and ST segment elevation due to severe hypokalemia. This will lead to accurate measuring decisions by treating hypokalemia and avoiding activating the catheterization laboratory, performing an unnecessary intervention.

Background

Point-of-care transthoracic echocardiography can be useful in diagnosing a pulmonary embolism in patients with hemodynamic instability and facilitate with their management in the emergency department.

Case report

A 64 year-old man presented to the ED with several days of worsening exertional dyspnea associated with left-sided chest pain who was hemodynamically unstable. Point-of-care ultrasound revealed a clot in the right atrium, which led to further assessment of the right heart function to detect signs of acute right heart strain when a pulmonary embolism is highly suspected.

Why should an emergency physician be aware of this?

Point-of-care ultrasound (POCUS) was utilized to evaluate characteristic findings that will predict a higher risk of deterioration from a pulmonary embolism. Rarely, a mobile clot can be seen within the right atrium which is highly specific for imminent pulmonary embolism and is associated with higher risk of decompensation. Bedside transthoracic echocardiogram allowed for rapid diagnostic assessment that guided decision making and early management of pulmonary embolism, which can improve the patient's outcome.

Background

Computed Tomography (CT) use is common during emergency department (ED) visits, and ED clinicians may order CTs for myriad reasons, including desire to improve patient satisfaction.

Objectives

To determine if greater CT use by ED clinicians is associated with increased average patient satisfaction scores for those providers.

Methods

The study took part across 15 non-pediatric hospitals in a regional healthcare system. We compared clinician CT use rate for adult patients discharged from the ED with Net Promotor Score (NPS) for that clinician. NPS is a patient satisfaction metric with a possible range of scores from −100 to +100. We included ED clinicians (physicians and non-physician providers (NPPs)) with at least 500 adult patient encounters resulting in ED discharge from July 2020 through June 2022. We assessed for an association between CT use and clinician NPS using univariate and multivariate regression models.

Results

Across the 15 hospitals, 166 physicians and 74 NPPs were included in the study. The median CT rate was 25.7 ​% (range 7.1 ​%–48.9 ​%). In both models, there was a statistical association between CT utilization and NPS such that every absolute increase in CT use by 10 ​% resulted in a 3-point improvement in provider NPS on the 200-point scale. When examined in a sensitivity analysis, none of the hospitals individually showed this same association.

Conclusions

We found a 26 ​% rate of CT use by clinicians for adults discharged from the ED, with wide variation in utilization between clinicians. There was a small and inconsistent association between CT utilization and clinician specific NPS scores.

Background

Interventional management for primary spontaneous pneumothoraces (PSPs) appears to have become the norm, with conservative management having been pushed into the background over the past few decades. In the UK, management of PSPs is guided by the British Thoracic Society (BTS) Guidelines. While original guidance, dating back to 2011, favoured interventional management, the newly released updated BTS algorithm has given the conservative approach greater visibility.

Case report

A teenager presented to the Emergency Department after having developed sudden onset chest discomfort. A chest x-ray confirmed a PSP. He was admitted and initially treated conservatively. After 24 hours of observation, a chest drain was inserted on the basis of a lack of radiologic improvement. On discharge after chest drain removal, he was found to have a recurrence of his pneumothorax when reviewed at the outpatient respiratory clinic. He was again managed conservatively, this time successfully.

Why should the emergency physician be aware of this?

This case raised several questions regarding the management of stable patients presenting with PSP. The body of evidence supporting conservative management as a safe and feasible option has been growing. It is therefore important for physicians to reconsider its role and value. While the newly released BTS guidelines are a step in the right direction, there are a number of important questions to address in order to both effectively guide emergency physicians and for conservative management to be used in a more standardised and routine way.

Background

Patients with hip fractures frequently present to the emergency department (ED). Traditional methods of pain control often include the use of opioid pain medication. Fascia iliaca nerve blocks offer an alternative method to acute pain management in the ED for hip fractures. At the time of this publication, there are no readily available, cost-effective gelatin models of the surrounding fascia iliaca anatomy.

Objectives

The objective was to design an accurate and cost-effective model to simulate fascia iliaca nerve block models for training emergency medicine clinicians.

Discussion

A gelatin model was created to simulate the anatomy of the inguinal region in order to perform a fascia iliaca block. This fascia iliaca nerve block model aided in training of residents and attendings to become familiar with the anatomy and techniques necessary to perform this nerve block. Clinicians were able to practice ultrasound guided in-plane approach into the fascia iliaca space where they could then hydrodissect and distill anesthetic. Each model could be used several times allowing trainees multiple attempts.

Conclusion

A method to create a fascia iliaca nerve block model using readily available supplies was designed to aid training of emergency medicine clinicians. We hope to improve the technique and clinician comfort-level when performing the fascia iliaca nerve block using this model.