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BACKGROUND: Acute ischemic stroke (AIS) in pediatric populations accounts for more than half of pediatric strokes and is associated with significant morbidity and mortality. Pediatric AIS can present with nonspecific symptoms or symptoms that mimic alternate pathology. CASE REPORT: A 4-month-old female presented to the emergency department for fever, decreased oral intake, and "limp" appearance after antibiotic administration. She was febrile, tachypneic, and hypoxic. Her skin was mottled with 3-s capillary refill, her anterior fontanelle was tense, and she had mute Babinski reflex bilaterally but was moving all extremities. The patient was hyponatremic, thrombocytopenic, and tested positive for influenza A. A computed tomography scan of the brain revealed an acute infarction involving the right frontal, parietal, temporal, and occipital lobes in addition to hyperdensities concerning for thrombosed cortical veins. The patient was transferred for specialty evaluation and was discharged 2 weeks later on levetiracetam. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pediatric AIS can present with nonspecific symptoms that mimic alternate pathology. A high level of suspicion is needed so as not to miss the diagnosis of pediatric AIS in the emergency department. A thorough neurologic assessment is warranted, and subtle abnormalities should be investigated further.
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Gripe Humana/complicaciones , Accidente Cerebrovascular/diagnóstico , Femenino , Fiebre/etiología , Humanos , Hipoxia/etiología , Lactante , Gripe Humana/fisiopatología , Levetiracetam/uso terapéutico , Nootrópicos/uso terapéutico , Accidente Cerebrovascular/tratamiento farmacológico , Accidente Cerebrovascular/fisiopatología , Taquicardia/etiología , Tomografía Computarizada por Rayos X/métodosAsunto(s)
Arritmias Cardíacas/diagnóstico , Diagnóstico Diferencial , Electrocardiografía/normas , Anciano de 80 o más Años , Arritmias Cardíacas/fisiopatología , Electrocardiografía/métodos , Servicio de Urgencia en Hospital/organización & administración , Humanos , Masculino , Monitoreo Fisiológico/métodos , Debilidad Muscular/etiología , Torsades de Pointes/diagnóstico , Torsades de Pointes/fisiopatologíaAsunto(s)
Rótula/lesiones , Luxación de la Rótula/terapia , Adulto , Reducción Cerrada/métodos , Servicio de Urgencia en Hospital/organización & administración , Humanos , Masculino , Rótula/diagnóstico por imagen , Luxación de la Rótula/diagnóstico por imagen , Radiografía/métodos , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnóstico por imagenRESUMEN
Study objectives Although the focused assessment with sonography in trauma (FAST) examination was initially developed for rapid evaluation of trauma patients, the basic skillset required to perform a FAST examination provides valuable information that may alter a non-trauma patient's clinical course. The objective of this study was to determine the utility of the FAST examination in the emergency department management of non-trauma patients. Methods Cases in which the FAST examination was used to direct care in non-trauma patients were retrospectively reviewed. Following the completion of the patient's care, emergency physicians were asked to complete a questionnaire indicating how information from the FAST examination was utilized to direct care of their non-trauma patients. Results A total of 63 non-trauma cases with average age of 48 years (range 16-94 years) were enrolled. The FAST examination positively impacted care in 57/63 (90.5%) cases. In 18/63 (28.6%) cases, the patient's ultimate disposition changed because of FAST examination findings. In 9/63 (14.3%) cases, paracentesis was avoided by obtaining a FAST examination, and in 8/63 cases (12.7%) paracentesis was performed due to FAST examination results. In 16/63 (25.4%) cases, anticipated imaging changed due to FAST examination findings and 4/63 (6.3%) cases did not receive the anticipated computed tomography (CT) scan. Conclusions Although initially developed for evaluation of trauma patients, the FAST examination can provide valuable information that can positively impact care in non-trauma patients. The FAST examination can provide information to determine appropriate patient disposition, obtain appropriate additional imaging, ensure timely consultation, and eliminate risk from unnecessary procedures.
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BACKGROUND: Emergency medicine milestones released by the Accreditation Council for Graduate Medical Education require residents to demonstrate competency in bedside ultrasound (US). The acquisition of these skills necessitates a combination of exposure to clinical pathology, hands-on US training, and feedback. OBJECTIVES: We describe a novel simulation-based educational and assessment tool designed to evaluate emergency medicine residents' competency in point-of-care echocardiography for evaluation of a hypotensive patient with chest pain using bedside US. METHODS: This was a cross-sectional study conducted at an academic medical center. A simulation-based module was developed to teach and assess the use of point-of-care echocardiography in the evaluation of the hypotensive patient. The focus of this module was sonographic imaging of cardiac pathology, and this focus was incorporated in all components of the session: asynchronous learning, didactic lecture, case-based learning, and hands-on stations. RESULTS: A total of 52 residents with varying US experience participated in this study. Questions focused on knowledge assessment demonstrated improvement across the postgraduate year (PGY) of training. Objective standardized clinical examination evaluation demonstrated improvement between PGY I and PGY III; however, it was noted that there was a small dip in hands-on scanning skills during the PGY II. Clinical diagnosis and management skills also demonstrated incremental improvement across the PGY of training. CONCLUSION: The 1-day, simulation-based US workshop was an effective educational and assessment tool at our institution.
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BACKGROUND: Compartment syndrome occurs when an increase in pressure results in vascular and functional impairment of the underlying nerve and muscles. Thigh compartment syndrome (TCS) is uncommon, but clinical suspicion warrants emergent surgical consultation and fasciotomy. CASE REPORT: We present a 42-year-old man evaluated for right lateral thigh pain, without a history of trauma, deep venous thrombosis (DVT), previous surgery, or intravenous drug use. He was febrile, tachycardic, with a mild leukocytosis, an elevated C-reactive protein level, and an elevated creatinine kinase level. Radiographs showed no abnormality and right lower extremity duplex ultrasound showed no DVT. A computed tomography scan of the right lower extremity was concerning for compartment syndrome. Surgical consultation was obtained, and the patient was taken to the operating room for fasciotomy. He was diagnosed with compartment syndrome intraoperatively. The patient was discharged on hospital day 10. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TCS is exceedingly rare, especially in the absence of underlying traumatic and nontraumatic etiologies. The diagnosis is challenging because more elastic fascia with larger space in the thigh allows for accommodation of acute increases in pressure. Consequently, there may not be the expected acute rise in compartment pressures; increased compartment pressure may only be a late sign, when underlying neurovascular damage has already occurred. TCS is complicated by high morbidity and mortality. Emergent surgical consultation should be obtained when there is a high clinical suspicion for TCS, and limb-saving fasciotomy should not be delayed. This case shows the importance of a high level of suspicion for TCS in patients with no identifiable etiology and no historical risk factors for development of compartment syndrome, because TCS may not present with classic symptoms.
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Síndromes Compartimentales/diagnóstico , Síndromes Compartimentales/cirugía , Muslo/irrigación sanguínea , Adulto , Proteína C-Reactiva/análisis , Fasciotomía/métodos , Fiebre/etiología , Humanos , Masculino , Taquicardia/etiología , Muslo/lesiones , Tomografía Computarizada por Rayos X/métodosRESUMEN
OBJECTIVES: The purpose of this investigation was to compare the incidence of esophageal intubations (EIs) when emergency medicine (EM) residents used a direct laryngoscope (DL) versus a video laryngoscope (VL) for intubation attempts in the emergency department (ED). METHODS: Prospectively collected continuous quality improvement data on tracheal intubations performed by EM residents in an academic ED over a 6-year period were retrospectively analyzed. Following each intubation, EM residents completed a data form with patient, intubation, and operator characteristics. Data collected included the method of intubation, drugs used, device(s) used, number of attempts, outcome of each attempt, occurrence of EIs, and occurrence of adverse events (hypoxemia, aspiration, dysrhythmia, hypotension, and cardiac arrest). The incidence of EI was compared between intubation attempts with a DL and with a VL (GlideScope(®) or C-MAC(®) ). Propensity score matching and conditional logistic regression were used to analyze the association between the intubation device (DL vs. VL) and EI. RESULTS: Over the 6-year period, 2,677 patients underwent 3,425 intubation attempts by EM residents with a DL or a VL. A DL was used in 1,530 attempts (44.7%) and a VL was used in 1,895 attempts (55.3%). There were 96 recognized EIs (2.8%). The incidence of EI when using a DL was 78 of 1,530 attempts (5.1%; 95% confidence interval [CI] = 4.1% to 6.3%) and when using a VL was 18 of 1,895 attempts (1.0%; 95% CI = 0.6% to 1.5%). Based on the propensity score matched analysis, the odds ratio for the occurrence of an EI for DL versus VL was 6.9 (95% CI = 3.3 to 14.4). Patients who had inadvertent EIs had a higher incidence of adverse events (49.5%; 95% CI = 38.9% to 60.0%) than patients in which EI did not occur (19.8%; 95% CI = 18.3% to 21.4%). CONCLUSIONS: The use of a VL by EM residents during an intubation attempt in the ED was associated with significantly fewer EIs compared to when a DL was used. Patients who had inadvertent EIs had significantly more adverse events than those who did not have EIs. EM residency training programs should consider using VLs for ED intubations to maximize patient safety when EM residents are performing intubation.
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Medicina de Emergencia/educación , Servicio de Urgencia en Hospital/estadística & datos numéricos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/estadística & datos numéricos , Laringoscopía/instrumentación , Centros Médicos Académicos , Adulto , Anciano , Femenino , Humanos , Internado y Residencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Seguridad del Paciente , Puntaje de Propensión , Estudios Prospectivos , Mejoramiento de la Calidad , Centros de Atención TerciariaRESUMEN
OBJECTIVE: To compare the effectiveness of the C-MAC® video laryngoscope (CMAC) to the direct laryngoscope (DL) when used to rescue a failed first attempt intubation in the emergency department (ED). METHODS: Data were prospectively collected on all patients intubated in an academic ED center over a five-year period from February 1, 2009 to January 31, 2014 when both the CMAC and the DL were available. Following each intubation the operator completed a continuous quality improvement (CQI) form documenting patient, operator and intubation characteristics. All orotracheal intubations attempted by emergency physicians (EPs) on adult patients with a failed first intubation attempt, and in which the CMAC or the DL was used for the second attempt, were included. The primary outcome was successful intubation on the second attempt using either the CMAC or the DL. A multivariate logistic regression analysis was performed to adjust for potential confounders. RESULTS: During the five-year study period, there were 460 adult orotracheal intubation attempts by EPs which were not successful on the first attempt. In 398 (86.5%) of these cases the same operator performed the second attempt. The CMAC was utilized for the second attempt in 141 cases and was successful in 116 (82.3%; 95% CI 75.0%-88.2%) and the DL was utilized in 94 cases and was successful in 58 (61.7%; 95% CI 51.1%-71.5%). In a multivariate logistic regression analysis the CMAC was associated with an increased odds (adjusted OR 3.5; 95% CI 1.9-6.7) of a second attempt success compared to the DL. CONCLUSIONS: After a failed first intubation attempt in the ED, regardless of the initial device used, the CMAC was more successful than the DL when used for the second attempt. This suggests that the CMAC is the preferred rescue device after an initial intubation attempt in the ED fails.
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Intubación Intratraqueal/instrumentación , Laringoscopios , Laringoscopía/instrumentación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Servicio de Urgencia en Hospital , Femenino , Humanos , Laringoscopía/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Mejoramiento de la Calidad , Insuficiencia del Tratamiento , Adulto JovenRESUMEN
A 54-year-old man treated with dabigatran experienced new onset of a stroke with a score of 9 on the National Institutes of Health Stroke Scale. Administration of recombinant tissue plasminogen activator (rtPA) was not recommended because of the dabigatran therapy. Angiography showed occlusion of the left middle cerebral artery by an embolic thrombus. Suction thrombectomy achieved flow through the inferior division of the artery. Computed tomography of the head showed possible intracranial hemorrhage, and dabigatran reversal was attempted with prothrombin complex concentrate and recombinant factor VIIa. Coagulation studies before administration of the reversal blood products showed a partial thromboplastin time of 30.3 seconds; 1 hour after administration, the partial thromboplastin time was 28.5 seconds. No evidence of intracranial hemorrhage was apparent on repeated computed tomography scans of the brain. He was discharged with aspirin and warfarin and a stroke score of 8. (American Journal of Critical Care. 2013;22:169-176) The use of long-term oral anticoagulation is indicated for prevention of cardiac thromboembolism in selected patients with nonvalvular atrial fibrillation. With the emergence of new potent oral agents- including the selective direct thrombin inhibitor dabigatran-clinicians must become familiar with the management of such patients. In this case report, we present a man who had an acute ischemic stroke while taking dabigatran and discuss the medical decision making regarding management issues.
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Bencimidazoles/efectos adversos , Hemorragias Intracraneales/tratamiento farmacológico , Trombosis Intracraneal/cirugía , Piridinas/efectos adversos , Accidente Cerebrovascular/tratamiento farmacológico , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Bencimidazoles/administración & dosificación , Bencimidazoles/uso terapéutico , Angiografía Cerebral , Coagulantes/administración & dosificación , Coagulantes/uso terapéutico , Dabigatrán , Quimioterapia Combinada , Factor VIIa/administración & dosificación , Factor VIIa/uso terapéutico , Humanos , Hemorragias Intracraneales/inducido químicamente , Hemorragias Intracraneales/diagnóstico , Trombosis Intracraneal/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Protrombina/administración & dosificación , Protrombina/uso terapéutico , Piridinas/administración & dosificación , Piridinas/uso terapéutico , Proteínas Recombinantes/administración & dosificación , Proteínas Recombinantes/uso terapéutico , Índice de Severidad de la Enfermedad , Accidente Cerebrovascular/clasificación , Accidente Cerebrovascular/complicaciones , Succión , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Lumboperitoneal shunt (LPS), ventriculoperitoneal shunt (VPS) and optic nerve sheath fenestration (ONSF) are accepted surgical therapies for medically refractory idiopathic intracranial hypertension (IIH). In the subset of patients with IIH and venous sinus stenosis, dural venous sinus stenting has emerged as an alternative surgical approach. METHODS: All cases of dural stents for IIH at our institution were retrospectively reviewed. Eligibility criteria included medically refractory IIH with documented papilledema and dural venous sinus stenosis of the dominant venous outflow system (gradient ≥10 mm Hg). RESULTS: Fifteen cases (all women) of mean age 34 years were identified. All had failed medical therapy and six had failed surgical intervention. Technical success was achieved in all patients without major periprocedural complications. The mean preprocedural gradient across the venous stenosis was reduced from 24 mm Hg before the procedure to 4 mm Hg after the procedure. Headache resolved or improved in 10 patients. Papilledema resolved in all patients and visual acuity stabilized or improved in 14 patients. There were no instances of restenosis among the 14 patients with follow-up imaging. CONCLUSION: In this small case series, dural sinus stenting for IIH was performed safely with a high degree of technical success and with excellent clinical outcomes. These results suggest that angioplasty and stenting for the treatment of medically refractory IIH in patients with dural sinus stenosis warrants further investigation as an alternative to LPS, VPS and ONSF.