Journal of education & teaching in emergency medicine最新文献

Soft tissue infections, including abscesses, are frequently encountered in the emergency department. However, abscesses of the inferior rectus muscle are rare and may present unique diagnostic and therapeutic challenges due to the scarcity of documented cases. This case report highlights the treatment of a 47-year-old male presenting with an abscess in the left inferior rectus muscle due to an acute Methicillin-resistant Staphylococcus aureus infection. Imaging revealed a distinct fluid collection compressing the left globe, causing restricted ocular motility and other symptoms. Despite prior intravenous antibiotics, the abscess persisted. While intravenous antibiotics are an important component of treatment, this case highlights the potential insufficiency of this approach alone, emphasizing a need for surgical intervention such as orbitotomy for drainage. This report contributes to the limited literature on inferior rectus muscle abscesses and underscores the need for further research and clinical attention to optimize patient outcomes.

Topics: Abscess, soft tissue infection, extraocular muscles, pyomyositis, Methicillin-resistant Staphylococcus aureus, proptosis, diplopia, vision loss.

Unstable cervical spine (c-spine) fractures are of high concern in traumatic incidents because they may result in significant morbidity and mortality. This is a case of a 44-year-old male who presents to the Emergency Department (ED) with neck pain after recreational wrestling and was found to have an unstable C-spine fracture. His treatment course was complicated by multiple interrupted hospital stays due to leaving against medical advice (AMA) and subsequent returns to the emergency department. The patient received both CT and MRI imaging and ultimately underwent occiput to C3 fusion with drain placement with a favorable outcome. This case report highlights the diagnosis and treatment of a patient with an unstable c-spine fracture. Key lessons from the case include the importance of timely recognition of patients with a potential c-spine fracture and identifying those who are at risk for nonadherence to medical treatment plans in order to provide interventions and improve chances of adherence. For patients in which pre-hospital care is involved, such as emergency medical services (EMS), recognition and appropriate care, such as c-spine stabilization, may be important for long-term outcomes.

Topics: Unstable c-spine fracture, polysubstance use, spinal injury, neck trauma.

An 18-year-old female presented to the emergency department (ED) with two days of right lower quadrant pain and associated nausea and emesis. After relevant information was gathered and with physical exam findings of a tender right lower quadrant, positive psoas sign, positive Rovsing sign, and pain with right heel tap, the patient was presumed to have appendicitis. However, imaging contradicted the initial leading diagnosis and revealed a markedly distended, hydropic gallbladder with its tip near the umbilicus. Findings of the distended gallbladder with marked wall thickening and pericholecystic fat stranding and edema confirmed acute cholecystitis, and the patient was taken by general surgery for cholecystectomy. Together, this unusual presentation and this unexpected diagnosis shine light upon another facet of the hydropic gallbladder while also serving as a salient reminder to contemplate a broad differential regardless of seemingly classic presentations of illnesses.

Topics: Cholecystitis, hydropic gallbladder, abdominal pain, appendicitis.

Audience: This didactic session on distal radius fracture diagnosis and management is designed for Emergency Medicine (EM) residents of all levels.

Introduction: With an incidence of 1,130 upper extremity injuries per 100,000 persons per year,1 distal radius fractures (DRFs) are the most common adult fracture, representing 17.5% of all fractures.2-4 Yet, many emergency medicine residents feel unprepared to manage DRFs independently upon graduation.5 The standard management of a fracture in the ED setting consists of identifying any urgent aspects of the fracture, controlling pain, performing a reduction if necessary, and applying a splint.6 Poor reduction or splinting techniques can lead to serious complications, including acute carpal tunnel or compartment syndrome, development of severe burns and rarely, amputation.6-8 Though it is common for emergency medicine (EM) resident trainees working in academic institutions to have regular access to orthopaedic surgery consultation, many will go on to practice in community settings or departments without access to full-time orthopaedic coverage. It is essential for EM residents to be familiar with DRF diagnosis and management, including closed reduction and splinting. We seek to create a toolbox for managing upper extremity fractures, with the overall purpose of improving orthopaedic care in the ED setting.

Educational objectives: By the end of this didactic session, learners should be able to: 1) assess DRF displacement on pre-reduction radiography and formulate reduction strategies, 2) perform a closed reduction of a DRF, 3) apply a safe and appropriate plaster splint to patient with a DRF and assess the patient's neurovascular status, 4) assess DRF post-reduction radiography for relative fracture alignment, and 5) understand appropriate follow-up and necessary return precautions.

Educational methods: Learners attended a didactic session led by orthopaedic surgery residents which included a faculty-approved lecture on DRFs and hands-on skills workshop on reducing the fractures and effectively applying plaster splints.

Research methods: Prior to the educational session, participants completed a pre-workshop survey assessing current practices and baseline confidence regarding DRF management. Self-confidence levels for each skill were measured using a Likert scale from 0 (least confident) to 100 (most confident). Confidence levels were re-assessed immediately after the didactic session and three months later.

Results: Nineteen emergency medicine (EM) residents (n=12, 63% female) across three class years (n=9, 47% PGY 1; n=6, 32% PGY 2; n=4, 21% PGY 3) completed the pre-workshop survey, and 15 residents participated in the didactic session and completed follow-up surveys. Fourteen (75%) EM residents reported reducing DRFs on their own (without an orthopaedic consult) less

Myasthenia gravis (MG) is an autoimmune disorder of the neuromuscular junction that can cause various symptoms provoking a visit to the emergency department (ED). In this case, we present a 54-year-old female who reported having her eyes "taped open" for the last two months. Her history and physical exam findings in the ED raised suspicion for MG. The patient was subsequently admitted and started on pyridostigmine. An elevated acetylcholinesterase receptor-binding antibody level confirmed the diagnosis of MG. This case report highlights the characteristic progressive weakness of facial muscles in MG, emphasizing the importance of early recognition of MG symptoms by emergency clinicians in order to initiate appropriate management and prevent respiratory compromise and morbidity.

Topics: Neurology, neurologic exam, myasthenia gravis, emergency medicine.

The presentation of erythema multiforme in the emergency department is relatively rare, thus recognition and rapid intervention requires a high index of suspicion. This study presents a case of a 55-year-old female with past medical history of hypertension and active endometrial cancer with recent chemotherapy treatment complaining of four days of progressive erythematous rash with associated pruritis and blistering. An exam found multiple tense, scattered vesicles with an erythematous base. The patient also demonstrated leukopenia, elevated alkaline phosphatase level, and elevated C-reactive protein level. A shave biopsy was performed and intravenous acyclovir was started for concern of varicella-zoster virus. Biopsy results favored an erythema multiforme diagnosis, and she was discharged with topical clobetasol. In addition to reviewing the presentation and intervention of erythema multiforme, this case report adds to growing literature of erythema multiforme as a delayed reaction to malignancy therapy.

Topics: Erythema multiforme, dermatology, radiotherapy.

A 78-year-old gentleman presented to the emergency department (ED) for palpitations and dizziness. He had a complicated medical history including atrial fibrillation (AF), recently status post a Watchman procedure, oxygen-dependent chronic obstructive pulmonary disease (COPD), and heart failure with preserved ejection fraction (HFpEF). Point-of-care ultrasound (POCUS) revealed the presence of an intracardiac right atrial thrombus. Computed tomography (CT) angiography confirmed the presence of multiple pulmonary emboli (PE), and extension of the thrombus into the inferior vena cava. Pulmonary emboli are a common complication of thrombus in the right atrium. Management may include anticoagulation, thrombolysis, or thrombectomy. This case highlights that emergency physicians can expedite the diagnosis of intracardiac thrombus by using POCUS. The case presented describes a medically complex patient presenting with symptomatic right intracardiac and inferior vena caval thrombosis complicated by multiple PE. Point-of care ultrasound of the heart and lungs were included in his initial assessment, revealing findings of an intracardiac thrombus, and ruling out multiple other differential diagnoses including pericardial tamponade, pleural effusion, pulmonary edema, and pneumothorax. This finding changed the trajectory of this patient's evaluation and management, and demonstrates the important role of POCUS in the care of ED patients with undifferentiated cardiopulmonary symptoms.

Topics: Point-of care ultrasound (POCUS), focused cardiac ultrasound (FOCUS), inferior vena cava thrombosis, right atrial thrombosis, pulmonary embolism, computed tomography, echocardiography.