ResearchPad - Emergency Medicine https://www.researchpad.co Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Qualities Important in the Selection of Chief Residents]]> https://www.researchpad.co/article/elastic_article_11611 Background

Chief resident selection occurs by numerous methods. Chief residents also fulfill multiple roles, requiring a broad skill set. However, there is little literature on which qualities various stakeholders value in chief resident selection. The objective of this study was to identify the qualities that residents and faculty believe are important for chief residents.

Methods

Following a literature review, educational experts conducted a multi-institutional survey that asked participants to name the qualities they felt were most important in chief residents and to rank-order a predefined list of 10 qualities. Associations were calculated between rank-order and participant age, gender, institutional position, and history of serving as a chief resident.

Results

The response rate for the survey was 43.9% (385/877). Leadership, organization, and communication skills were named by all participants among the most common responses. Residents additionally named approachability, advocacy, and listening skills among their most valued qualities, whereas faculty named strong clinical skills and integrity. Dependability and trustworthiness were the most valued qualities in the rank-order list, whereas strong clinical skills and self-reflection were the least valued. Females valued the ability to manage multiple demands more whereas males valued dependability more. The faculty valued strong clinical skills more than residents.

Conclusion

A variety of qualities are seen as being valuable in chief residents. Additional research is needed to understand what qualities are associated with effective chief resident performance.

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<![CDATA[Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome as a Presentation of Coronavirus Disease 2019]]> https://www.researchpad.co/article/elastic_article_10511 The novel coronavirus disease 2019 (COVID-19) has led to a global pandemic. While acute respiratory failure has been the predominant concern, there have been reports of other end-organ damage such as renal failure. We report a case of an elderly woman who presented with BRASH syndrome, a constellation of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH), which was likely triggered by COVID-19.

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<![CDATA[Serum Procalcitonin Level Is Associated with Positive Blood Cultures, In-hospital Mortality, and Septic Shock in Emergency Department Sepsis Patients]]> https://www.researchpad.co/article/elastic_article_10499 This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

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<![CDATA[Severe Kidney Injury After a 110-km Trail Race]]> https://www.researchpad.co/article/elastic_article_10498 We present a case of severe, acute kidney injury, rhabdomyolysis and dehydration in a 49-year-old, competitive trail runner, after a 110-km trail race in mountainous terrain. Six days after the event, he presented to the hospital with fatigue, weight gain and oedema. Biochemically the diagnosis of severe, acute kidney injury was made, with increased serum creatinine levels of 13.4 mg/dL (normal range 0.67-1.17 mg/dL). He remained hospitalised for two weeks, and improved with conservative measures, without the need for renal replacement therapy. Likely risk factors included ingestion of non-steroidal anti-inflammatory drugs prior to the event, dehydration and prolonged running in mountainous environment at moderate altitude. Renal function largely returned to baseline levels four months after initial presentation. This case highlights that severe kidney injury can occur, even days after ultra-running events, especially in the presence of associated risk factors. If repeated cases of acute kidney injury can trigger chronic kidney injury is currently unclear and further research in this area is warranted. In the meantime, efforts should be made to educate athletes, coaches and health care professionals about the dangers of acute kidney injury and associated risk factors.

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<![CDATA[Diagnosis and Management of Iatrogenic Hemobilia Secondary to Transjugular Intrahepatic Portosystemic Shunt Procedure]]> https://www.researchpad.co/article/elastic_article_9462 A patient with end-stage liver disease and subsequent refractory ascites was treated with a transjugular intrahepatic portosystemic shunt (TIPS) procedure. The procedure was complicated by massive gastrointestinal hemorrhage with associated rettorragia. Computed tomography angiography (CT-A) was performed and revealed haemobilia due to an artero-biliary fistula between the right hepatic artery and an intrahepatic biliary branch. The patient underwent an attempt at percutaneous embolization. Bleeding was successfully stopped by the embolization of the fistula with coils.

Hemobilia is a rare cause of upper gastrointestinal bleeding with an increasing incidence due to the widespread use of invasive hepatobiliary procedures. Hemobilia is an uncommon complication of TIPS procedures. Nowadays, transcatheter embolization is the gold standard in the management of hemobilia.

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<![CDATA[Acute Calcific Retropharyngeal Tendinitis with Eggshell-like Calcification: Case Report and Literature Review on Time-course Changes in Imaging Findings]]> https://www.researchpad.co/article/elastic_article_9454 Acute calcific retropharyngeal tendinitis is a rare disease, and few studies have reported the radiological findings of its time-course in detail. These radiological findings vary according to the calcific stage. We report a case of acute calcific retropharyngeal tendinitis with eggshell-like calcification detected on follow-up computed tomography (CT). We also review pertinent literature on calcific retropharyngeal tendinitis, with a focus on time-course changes in imaging findings.

A 54-year-old Japanese woman presented with acute severe neck pain. She also had a limited range of motion in the rotation of her neck and moderate pain and discomfort during swallowing. Plain radiographs of the cervical spine showed no apparent abnormality. CT revealed massive retropharyngeal calcification in front of the C1-C2 vertebrae. The patient was diagnosed with acute calcific retropharyngeal tendinitis and treated with a soft collar and non-steroidal anti-inflammatory drugs. Two weeks later, the neck pain and dysphagia improved. At the one-month follow-up, CT showed residual marginal calcification, which was diminishing in size, suggesting eggshell-like calcification.

We believe that although the eggshell calcification appearance is extremely rare, it is important to note this atypical presentation of acute calcific retropharyngeal tendinitis.

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<![CDATA[Development and validation of a questionnaire to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy]]> https://www.researchpad.co/article/elastic_article_7826 Cardiac arrest is rare in pregnancy, and up-to date competence can be difficult to assess and maintain. The objective of this study was to develop and validate a questionnaire to assess healthcare personnel experiences, self-assessed competence and perception of role and resposibility related to cardiac arrest and cardio-pulmonary resuscitation (CPR) in pregnancyMethodsThe study had a cross-sectional design, developing and validating a questionnaire: the Competence in cardiac arrest and CPR in pregnancy (ComCA-P). Development and validation of the ComCA-P was conducted in three stages: 1) Literature review and expert group panel inputs, 2) a pilot study and 3) a cross-sectional questionnaire study. In stage one, the ComCA-P was developed over several iterations between the researchers, including inputs from an expert group panel consisting of highly competent professionals (n = 11). In stage two, the questionnaire was piloted in a group of healthcare personnel with relevant competence (n = 16). The ComCA-P was then used in a baseline study including healthcare personnel potentially involved in CPR in pregnancy (n = 527) in six hospital wards. Based on these data, internal consistency, intra-class correlations, and confirmatory factor analysis were utilized to validate the questionnaire.ResultsThe expert group and pilot study participants evaluated the appropriateness, relevance and accuracy to be high. Formulation of the items was considered appropriate, with no difficulties identified related to content- or face validity. Cronbach’s alpha was 0.8 on the thematic area self-assessment, and 0.73 on the theoretical knowledge area of the ComCA-P. On both the self-assessed competence items and the teoretical knowledge items, Kaiser-Meyer-Olkin was 0.8. Moreover, the Bertletts’ test of sphericity was greater than the critical value for chi-square, and significant (p < .0001).ConclusionsFindings indicate that the ComCA-P is a valid questionnaire that can be used to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy. ]]> <![CDATA[Effect of experimental, morphological and mechanical factors on the murine spinal cord subjected to transverse contusion: A finite element study]]> https://www.researchpad.co/article/elastic_article_8463 Finite element models combined with animal experimental models of spinal cord injury provides the opportunity for investigating the effects of the injury mechanism on the neural tissue deformation and the resulting tissue damage. Thus, we developed a finite element model of the mouse cervical spinal cord in order to investigate the effect of morphological, experimental and mechanical factors on the spinal cord mechanical behavior subjected to transverse contusion. The overall mechanical behavior of the model was validated with experimental data of unilateral cervical contusion in mice. The effects of the spinal cord material properties, diameter and curvature, and of the impactor position and inclination on the strain distribution were investigated in 8 spinal cord anatomical regions of interest for 98 configurations of the model. Pareto analysis revealed that the material properties had a significant effect (p<0.01) for all regions of interest of the spinal cord and was the most influential factor for 7 out of 8 regions. This highlighted the need for comprehensive mechanical characterization of the gray and white matter in order to develop effective models capable of predicting tissue deformation during spinal cord injuries.

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<![CDATA[Acute Subdural Haemorrhage as a Complication of Diagnostic Lumbar Puncture]]> https://www.researchpad.co/article/N4490b985-c36b-4876-aba4-bab700faebee Lumbar puncture (LP) is done daily for both spinal anesthesia and emergency cases for cerebrospinal fluid (CSF) analysis. Subdural hemorrhage (SDH) is a rare but severe complication following diagnostic LP, which could be potentially fatal, and early diagnosis may be life-saving. We present a 28-year-old female patient who presented to our emergency department with a headache, fever, and vomiting, with normal initial laboratory and imaging. Diagnostic lumbar puncture was done to exclude central nervous system infection. After CSF results and cultures were negative, and nasal influenza B detected, medication was started and she was discharged home. Three days post-procedure, she was complaining of a severe, persistent headache and a head computed tomography (CT) was done, which revealed acute SDH. Extensive workup searching for the cause of SDH was negative, and with a stationary course of SDH, she has discharged home again with a diagnosis of SDH post LP complication. In conclusion, a headache post LP is common and usually benign and self-limited. Severe persistent headache that is not positional and doesn't respond to analgesics with caffeine should be considered a red flag after LP and should be investigated carefully for other possibilities such as SDH.

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<![CDATA[First Case of an Infant with COVID-19 in the Middle East]]> https://www.researchpad.co/article/Ne4acc4e9-1173-47a8-8498-161f3f81e2e5 The novel coronavirus (COVID-19) has been declared a worldwide pandemic. It was initially thought to spare children and adolescents as significantly smaller number of cases have been reported in the pediatric population in comparison to adults. Here, we report the case of a 16-month-old female infant from Lebanon who presented with fever and severe diarrhea and tested positive for COVID-19. Her symptoms started six days prior to presentation with no cough, rhinorrhea, or other respiratory manifestations reported. Chest radiography showed lobar consolidation and bronchial infiltrates. Blood culture was positive for Streptococcus pneumoniae. Stool and urine cultures were negative. She was treated with ceftriaxone and metronidazole. Her RT-PCR test was negative after five days of treatment, suggesting that children can clear the virus faster than adults. The patient likely contracted the virus from her parents, who because of the fear of social stigma hide recent history of respiratory illness. These findings serve as a practical reference for the clinical diagnosis and medical treatment of children with COVID-19.

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<![CDATA[Novel Application of Point-of-Care Ocular Ultrasound in a Left Central Retinal Artery Occlusion]]> https://www.researchpad.co/article/N4d9d7fb2-72f2-44ec-8b00-9d1667c064be Central retinal artery occlusion represents a vision-threatening entity in those presenting with monocular painless vision loss, especially in the elderly and those with cardiovascular comorbidities. While confirmation of this diagnosis requires consultation with an ophthalmologist, prompt recognition is the crucial action of the emergency physician to help reverse retinal ischemia and save vision. Here we describe the case of a central retinal artery occlusion identified on point-of-care ocular ultrasound and confirmed by fluorescein angiography.

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<![CDATA[The Impact of Advanced Cardiac Life Support Simulation Training on Medical Student Self-reported Outcomes]]> https://www.researchpad.co/article/Nb0e2abb3-0d35-4627-bf9d-6cacab18d4de Introduction: Simulation has become a well-recognized and innovative tool in medical education. While there has been tremendous growth of simulation curricula at the level of graduate medical education, there have been few studies looking at simulation as a learning tool for undergraduate medical education. The goal of this study was to determine if high-fidelity simulation training impacts medical student perception of knowledge and confidence regarding comprehension and application of advanced cardiac life support (ACLS) algorithms.

Methods: This is a prospective observational survey study of third and fourth year medical students who participated in an ACLS simulation training during their emergency medicine rotation between January 2018 and October 2018. Cases covered several ACLS topics including unstable bradycardia, supraventricular tachycardia and ventricular tachycardia. After each session, students received a short survey to assess their simulation experience pertaining to knowledge and comfort levels with ACLS topics before and after the simulation experience.

Results: A total of 89 students were included in the study with 86.5% of those being fourth year students. There was a significant increase in both knowledge (pre-training 3.17 vs. 4.11 post-training, p<0.001) and comfort scores (pre-training 2.54 vs. 3.74 post-training, p<0.001) after the ACLS simulation training. Overall, 77.5% of students reported an increase in knowledge and 83.1% reported an increase in confidence after the training session. 

Conclusions: The study revealed a statistically significant increase in both perceived knowledge and comfort and confidence of medical students after high-fidelity simulation using ACLS scenarios.

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<![CDATA[Superior Mesenteric Artery Dissection After Lumbar Puncture]]> https://www.researchpad.co/article/N186d9125-0c1e-470d-bfc5-9fec941039f6 We hereby present a case of iatrogenic dissection of the superior mesenteric artery dissection in a 63-year-old female undergoing a lumbar puncture (LP). She presented with severe diffused abdominal pain accompanied by lower back pain, nausea and vomiting a few hours after undergoing an LP due to ongoing headaches. Abdominal CT showed evidence of hemoperitoneum. She was then transferred to another facility and while in route received one unit of packed red blood cellsdue to drop in hemoglobin levels from 15 to 11 gm/dl. Physicians should consider the possibility of arterial variations and the level at which spinal tap is performed during interventions. Acute abdominal pain is a significant, common complaint that should be appropriately investigated.

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<![CDATA[Successful Treatment of Cardiac Tamponade due to Rupture of the Heart Performing an Open-chest Pericardiotomy]]> https://www.researchpad.co/article/N25be801d-6cb0-4736-ba3c-d2fbb6c69c59

A 78-year-old woman with mild dementia was found unconscious by her family. She was transported by an ambulance to our emergency room (ER). Initially, she was comatose and in a state of shock. The echocardiographic findings suggested cardiac tamponade by hematoma. Computed tomography also showed tamponade without aortic dissection. After imaging, she went into cardiac arrest, was returned to the ER, and tracheal intubation and left thoracotomy for pericardiotomy were performed. A return of spontaneous circulation was obtained by following this procedure. Bleeding from a rupture of the left cardiac free wall was confirmed, and the rupture was closed with TachoSil®. After closing the thoracotomy, electrocardiography revealed ST elevation in the precordial leads. Subsequently, placement of an indwelling intra-aortic balloon pump and coronary angiography (CAG) were performed. CAG showed an occlusion of the anterior interventricular branch and circumflex branch of the left coronary artery. She underwent conservative therapy in a coronary care unit. Finally, after obtaining hemodynamic stability and baseline mental status, she was transferred to another medical facility.

We herein report a rare case involving the successful treatment of cardiac tamponade due to rupture of the heart performing an open-chest pericardiotomy and additionally discuss the key points for obtaining a favorable outcome.

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<![CDATA[Damage Control Management for Thoracic Trauma with Cardiac Arrest Complicated by Emphysematous Gastritis and Cystitis]]> https://www.researchpad.co/article/N55ff3b20-a67e-4067-a9d7-06b86110be40

A 78-year-old man was found unconscious after sliding from a rock. His history included hypertension, atrial fibrillation and cerebral infarction requiring warfarin. On arrival, he received six units of blood type O transfusion and vitamin K in an emergency room (ER) due to hemorrhagic shock. His systolic blood pressure temporarily increased to 100 mmHg, and he underwent traumatic pan scan revealing occipital fracture, cerebral contusion, and cervical and multiple left rib fractures with left-dominant bilateral hemothorax. He re-entered a shock state after the examination and underwent transfusion again, but he then entered cardiac arrest. He underwent damage control surgery in the ER and obtained spontaneous circulation. The postoperative course was eventful, but he eventually obtained a survival outcome. Damage control surgery may be beneficial, even in cases of severe thoracic blunt trauma; however, postoperative infections may cause severe problems.

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<![CDATA[Superior Optic Vein Thrombosis Related to Orbital Cellulitis Secondary to Aquatic Injury]]> https://www.researchpad.co/article/N51c448f7-bbfb-448d-aec8-f46adc052edb

A 52-year-old woman presented with orbital cellulitis and sixth cranial nerve palsy as a result of striking the tail of a stingray while swimming. Her ophthalmologic and neurologic examination showed injury of the conjunctiva, corneal abrasion without mention of foreign body, contusion of the eyelid, and isolated lateral gaze palsy and ptosis in the right eye. Orbital magnetic resonance (MR) imaging and MR venography showed orbital cellulitis, superior and lateral rectus edema, and thrombosis of the superior ophthalmic vein on the right eye. She was treated appropriately, and her physical examination showed significant improvement within three months.

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<![CDATA[Combatting Sedentary Lifestyles: Can Exercise Prescription in the Emergency Department Lead to Behavioral Change in Patients?]]> https://www.researchpad.co/article/Ne0792fe3-db83-4d5d-877f-d36137dfab98

Introduction

Emergency department (ED) patients with chronic disease are known to benefit from exercise; however, there are few studies examining the prescription of exercise in the ED. We asked, is exercise prescription in the ED feasible and effective?

Methods

In this pilot prospective block randomized trial, consented patients were divided into control and intervention groups. The control group received routine care. The intervention group received combined written and verbal prescriptions for moderate exercise of 150 minutes/week. Both groups were followed up by phone at two months. The primary outcome was achieving 150 minutes of exercise per week. Secondary outcomes included change in exercise and differences in reported median weekly exercise.

Results

Follow-up was completed for 23/28 patients (11 control; 12 intervention). Baseline reported median (with interquartile range) weekly exercise was similar between groups: control 0 (0-0) minutes, intervention 0 (0-45) minutes. There was no difference between groups for the primary outcome at two months (control 3/11; intervention 4/12, relative risk [RR] 1.33 (95% confidence interval [CI] 0.38-4.6; p=1.0). There was a significant increase in median exercise from baseline in both groups, but no difference between the groups (control 75 (10-225) minutes; intervention 120 (52.5-150) minutes; NS). A post hoc comparison of patients actually receiving intervention vs. no intervention revealed a significant increase in patients meeting the primary outcome (no intervention 0/8; intervention 7/15, RR 2.0 (95% CI 1.2-3.4); p=0.05).

Conclusion

The improvement seen in patients receiving the exercise prescription intervention, and the increase in reported exercise in both groups suggests that exercise prescription for ED patients may be beneficial.

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<![CDATA[Assembly Line Education: A Novel Educational Technique for Today's Learners]]> https://www.researchpad.co/article/N79e255b8-b9a7-48ff-90a6-c3d23aaa81f3

Background

Education is undergoing a transformation. The traditional passive lectures are failing to capture and inspire the new generation of learners who value more active and collaborative learning techniques.

Objective

We sought to create a novel educational technique to integrate into our curriculum that would be more personalized, employ more active learning and collaboration, and allow for an effective assessment of resident strengths and weaknesses.

Discussion

We created a monthly assembly line education academic half-day that evolved to replace one of the typical in-classroom didactics each month. Faculty run small-group simulation rooms, procedure workshops, competitive ultrasound, and wellness stations through which residents and medical students rotate.

Conclusion

This novel education technique resulted in a more personalized approach that increased resident interest, sparked the creation of a very popular MedEd-Simulation elective, and allowed the faculty to gain a better sense of resident strengths and deficiencies.

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<![CDATA[Chorea as the First Manifestation of Cerebral Infarction]]> https://www.researchpad.co/article/N538fac3f-a144-4b2e-9c8c-b286115ea533

Cerebrovascular disease (CVD), which usually manifests as a focal neurological deficit, is presented here as a movement disorder. This unusual manifestation corresponds to 1% of the CVDs and 8% of the striatal lesions. We report a 37-year-old right-handed woman who developed choreic movements as the first manifestation of an acute stroke. The computed tomography (CT) scan revealed a cortical/subcortical hypodense lesion in the right middle cerebral artery territory. This picture slowly improved and remitted completely after six weeks. Basal ganglia infarcts are crucial for the development of hemichorea, however, in spite of its frequency, movement disorders are disproportionally rare. In the majority of cases, the prognosis is good with spontaneous remission after two to four weeks.

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<![CDATA[Temporal Factors Associated With Opioid Prescriptions for Patients With Pain Conditions in an Urban Emergency Department]]> https://www.researchpad.co/article/Na188879e-3113-4c05-b65c-01a352d9c5e3

Key Points

Question

Have emergency department clinicians responded to the opioid epidemic through altering opioid prescription rates?

Findings

In this cross-sectional study of 556 176 emergency department patient encounters and 70 218 opioid prescriptions within a single emergency department, yearly prescriptions decreased by 66.3% between 2013 and 2018. This decrease was associated with a 71.1% reduction in the number of opioid prescriptions for musculoskeletal pain (back, limb, joint, and neck pain) and lesser, but still marked, decreases for fractures and kidney stones.

Meaning

Reductions in yearly opioid prescriptions across varying indications appear to be aligned with recognition of the opioid crisis in addition to national, state, and departmental education guidelines.

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