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Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (AirtraqⓇ; Prodol Meditec) and nonchanneled (McGrathⓇ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated. Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway. A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18–60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted. Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0–1 for group M and median IDS score of 1; IQR 0–2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A. The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques. [ABSTRACT FROM AUTHOR]

Hidradenitis suppurativa (HS) is a chronic immune-mediated inflammatory skin disease characterized by abscesses and inflammatory nodules, and occasionally tunnels and scars, in the axillae, groin, and inframammary areas. HS can be challenging to diagnose because it mimics localized soft-tissue infection. The process of differentiating HS from soft-tissue infection is discussed. Patients with HS frequently visit emergency departments (EDs) for acute management of pain and drainage from HS lesions. This review updates emergency and urgent care physicians on how to educate and initiate treatment for patients with HS, and to coordinate care with dermatologists and other physicians early in their disease course. Recent updates on the epidemiology, diagnosis, and management of HS are reviewed. Practice variations between how care for HS is provided in the ED setting and what HS treatment guidelines recommend are identified. [ABSTRACT FROM AUTHOR]

Background : Numerous studies have reported existing disparities in academic medicine. The purpose of this study was to assess racial and gender disparity in academic emergency medicine (EM) faculty positions across the United States from 2007 to 2018. Objective : The primary objective was to identify the racial and ethnic and gender distributions across academic ranks in EM. The secondary objective was to describe the racial and gender proportions across different tenure tracks and degrees. Methods : We conducted a retrospective analysis using data from the Association of American Medical Colleges. Simple descriptive statistics and time series analysis were employed to assess the trends and relationship between race and gender across academic rank, type of degree, and tenure status. Results : When averaged, 75% of all faculty members were White physicians and 67.5% were male. Asian faculty members showed an increased representation in the lower academic ranks and underrepresented minority groups demonstrated a small increase. Asian faculty members demonstrated a significantly increasing trend at the level of instructor (t = 0.02; p = 0.034; 95% CI 0.05–1.03). Female faculty members showed a significantly decreasing trend over the study period (t = –0.01; p < 0.001; 95% CI 0.68–0.75). White academic physicians and male faculty members made up most of all degree types and tenure categories. Conclusions : Despite an increase in proportional representation, the underrepresentation of female faculty members and those from minority groups persists in emergency medicine. Further studies are needed to identify and address the root causes of these differences. [ABSTRACT FROM AUTHOR]

Background: A pheochromocytoma-induced tako-tsubo syndrome is a life-threatening complication of the rare endocrinological disease. The association between the two syndromes is known, though seldom reported in literature, but the categorization is still debated.Case Report: In this article, we provide two examples of clinical presentation of this rare condition, its diagnosis using point-of-care ultrasound, its management in the emergency department, and finally, a literature review. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In case of a tako-tsubo syndrome-like myocardial dysfunction in a patient with unknown medical history, or recorded hypertensive or tachycardic peaks, a point-of-care ultrasound scan extended to the kidneys could help evaluate for a reversible underlying trigger cause such as pheochromocytoma. [ABSTRACT FROM AUTHOR]

Hyperglycemia in the inpatient setting contributes to morbidity and mortality. Glycemic management in the emergency room setting is the initial gateway for inpatient management. We gathered baseline glycemic data from January 2019 through November 2022 from the ACCC (Acute Cancer Care Center) at MD Anderson Cancer Center. For patients presenting to the ACCC between 2019 and 2022, the percentage with initial glucose level of 200-249mg/dL ranged from 6.64% to 7.5%, 3.33% to 6.4% with 250-299mg/dL, and 2% to 2.3% with of 300mg/dL or greater. 57.27% to 61.25% of patients were admitted inpatient and 20.67% to 29.73% were admitted with a POC glucose. Of those with known diabetes mellitus, 22.17% to 27% presented with an initial glucose of 200-249mg/dL, 12.17 % to 14% with 250 to 299mg/dL, and 6.92% to 8.75% with 300mg/dL or greater. Of those patients, 61.58% to 67.25% were admitted inpatient. In 2019, 48.9% of diabetes patients had a POC glucose order on admission compared to 39.08% in 2020, 43.17% in 2021, and 52.18% in 2022. In 2019, 76% had an insulin order on admission, 67.25% in 2020, 64.75% in 2021, and 63.09% in 2022. Of those patients with known diabetes 36.92% were admitted with an insulin sliding scale order in 2019, 25.58% in 2020, 26.17% in 2021, and 35.64% in 2022. Over the four years, the average initial blood glucose remained stable across both the general and diabetes specific populations. The admission rate for both these populations also had little variability. Of the patients with diabetes, the rate of POC glucose order at admission increased significantly from 39.08% to 52.18%. However, those with an insulin order decreased steadily from 76% to 63%. Additionally, only 25.58% to 36.92% of patients with diabetes were admitted with an insulin sliding scale order. These trends provide valuable insight into areas that may be targeted for early intervention in glycemic management which has the potential to improve hospital outcomes in patients with diabetes mellitus. [ABSTRACT FROM AUTHOR]

Background: Abnormal anatomy complicates emergency airway management. In this case, we describe definitive airway management in a critically injured emergency department (ED) patient with a history of partial tracheal resection who had a Montgomery T-tube, a type of T-shaped tracheal stent, in place at the time of the motor vehicle collision. The Montgomery T-tube is not a useful artificial airway during resuscitation, as it lacks a cuff or the necessary adapter for positive pressure ventilation.Case Report: We describe a case of a 51-year-old man who required emergency airway management after a motor vehicle collision. The patient had a Montgomery T-tube in place, which was removed with facilitation by ketamine sedation and topical anesthesia. The patient was successfully intubated through the tracheal stoma after removal of the T-tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must recognize the Montgomery T-tube, which resembles a standard tracheostomy tube externally, and have some understanding of how to manage a critically ill patient with this rare device in place. When a patient with a Montgomery T-tube in place requires positive pressure ventilation, the device may require emergent removal and replacement with a cuffed tracheostomy or endotracheal tube. [ABSTRACT FROM AUTHOR]

Background: Radicular low back pain is difficult to treat and commonly encountered in the Emergency Department (ED). Pain associated with acute radiculopathy results in limited ability to work, function, and enjoy life, and is associated with increased risk of chronic opioid therapy. In this case report, we describe the first ED-delivered ultrasound-guided caudal epidural steroid injection (ESI) used to treat medication-refractory lumbar radiculopathy, which resulted in immediate and sustained resolution of pain.Case Report: A 56-year old man with a past medical history of chronic lumbar radiculopathy presented to the ED with acute low back and right lower-extremity pain. Based on history and physical examination, a right L5 radiculopathy was suspected. His pain was poorly controlled despite multimodal analgesia, at which point he was offered admission or an ultrasound-guided caudal ESI. The procedure was performed using dexamethasone, preservative-free normal saline, and preservative-free 1% lidocaine solution, after which the patient reported 100% resolution of his pain and requested discharge from the ED. Why Should an Emergency Physician Be Aware of This? The safety and efficacy of ultrasound-guided caudal ESIs have been established, but there is a paucity of literature exploring their application in the ED. We present a case of a refractory lumbar radiculopathy successfully treated with an ultrasound-guided caudal ESI. ED-performed epidurals can be one additional tool in the emergency physician arsenal to treat acute or chronic lumbar radiculopathy. [ABSTRACT FROM AUTHOR]

Background: Angioedema is a complication that has been reported in up to 1.0% of individuals taking angiotensin-converting enzyme inhibitors (ACE-Is). Importantly, the onset of angioedema can occur anywhere from hours to several years after initiation of therapy with ACE-Is. Although most cases of ACE-I-induced angioedema (ACE-I-AE) are self-limiting, a major clinical concern is development of airway compromise, which can potentially require emergent airway management. The underlying pathophysiology of ACE-I-AE is incompletely understood, but is considered to be due in large part to excess bradykinin. Numerous medications have been proposed for the treatment of ACE-I-AE. This article is an update to the 2011 Clinical Practice Committee (CPC) statement from the American Academy of Emergency Medicine.Methods: A literature search in PubMed was performed with search terms angioedema and ACE inhibitors from August 1, 2012 to May 13, 2019. Following CPC guidelines, articles written in English were identified and then underwent a structured review for evaluation.Results: The search parameters resulted in 323 articles. The abstracts of these articles were assessed independently by the reviewers, who determined there were 63 articles that were specific to ACE-I-AE, of which 46 were deemed appropriate for grading in the final focused review.Conclusions: The primary focus for the treatment of ACE-I-AE is airway management. In the absence of high-quality evidence, no specific medication therapy is recommended for its treatment. If, however, the treating physician feels the patient's presentation is more typical of an acute allergic reaction or anaphylaxis, it may be appropriate to treat for those conditions. Any patient with suspected ACE-I-AE should immediately discontinue that medication. [ABSTRACT FROM AUTHOR]

Background: Patients with coronavirus disease 2019 (COVID-19) present with diagnostic challenges because COVID-19 can cause varied end-organ failures that mimic respiratory distress of pulmonary origin. Early identification of concurrent complications can significantly alter patient management and course. Point-of-care ultrasound (POCUS) can be particularly useful in helping to differentiate concomitant complications with COVID-19. While lung POCUS findings related to COVID-19 have been published, little guidance exists on how ultrasound can be incorporated into a more comprehensive evaluation of patients under investigation for COVID-19.Objectives: We devised a pathway called COVUS that incorporates POCUS into the initial evaluation of patients under investigation for COVID-19 to guide diagnosis and management.Discussion: The pathway was derived based on a review of literature, consensus from the ultrasound faculty, as well as feedback from the entire faculty group at one academic institution with high volumes of patients with COVID-19. The scanning protocol uses a cardiac-first (rather than lung-first) approach to identify potential concomitant organ failure that may immediately alter management.Conclusions: COVUS aims to maximize identification of the most immediately life-threatening complications while minimizing time at bedside and provider risk of exposure to COVID-19. [ABSTRACT FROM AUTHOR]

Background: The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly.Objective: This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician.Methods: We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management.Discussion: In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists.Conclusions: Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department. [ABSTRACT FROM AUTHOR]

Background: Emergency departments (EDs) need to be prepared to manage crises and disasters in both the short term and the long term. The coronavirus disease 2019 (COVID-19) pandemic has necessitated a rapid overhaul of several aspects of ED operations in preparation for a sustained response.Objective: We present the management of the COVID-19 crisis in 3 EDs (1 large academic site and 2 community sites) within the same health care system.Discussion: Aspects of ED throughput, including patient screening, patient room placement, and disposition are reviewed, along with departmental communication procedures and staffing models. Visitor policies are also discussed. Special considerations are given to airway management and the care of psychiatric patients. Brief guidance around the use of personal protective equipment is also included.Conclusions: A crisis like the COVID-19 pandemic requires careful planning to facilitate urgent restructuring of many aspects of an ED. By sharing our departments' responses to the COVID-19 pandemic, we hope other departments can better prepare for this crisis and the next. [ABSTRACT FROM AUTHOR]

Background: The coronavirus disease 2019 (COVID-19) pandemic has contributed to an increase in intimate partner violence (IPV), posing challenges to health care providers who must protect themselves and others during sexual assault examinations. Victims of sexual assault encountered in prehospital and emergency department (ED) settings have legal as well as medical needs. A series of procedures must be carefully followed to facilitate forensic evidence collection and law enforcement investigation. A literature review detected a paucity of published guidance on the management of sexual assault patients in the ED, and no information specific to COVID-19.Objective: Investigators sought to update the San Diego County sexual assault guidelines, created in collaboration with health care professionals, forensic specialists, and law enforcement, through a consensus iterative review process. An additional objective was to create a SAFET-I Tool for use by frontline providers during the COVID-19 pandemic.Discussion: The authors present a novel SAFET-I Tool that outlines the following five components of effective sexual assault patient care: stabilization, alert system activation, forensic evidence consideration, expedited post-assault treatment, and trauma-informed care. This framework can be used as an educational tool and template for agencies interested in developing or adapting existing sexual assault policies.Conclusions: There is a lack of clinical guidance for ED providers that integrates the many aspects of sexual assault patient care, particularly during the COVID-19 pandemic. A SAFET-I Tool is presented to assist emergency health care providers in the treatment and advocacy of sexual assault patients during a period with increasing rates of IPV. [ABSTRACT FROM AUTHOR]

Background: Successful airway management is critical to the practice of emergency medicine. Thus, emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this second part of a 2-part series.Objective: This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases commonly encountered in the emergency department.Discussion: Adverse events during emergent airway management are common with postintubation cardiac arrest, reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided by proper identification and understanding the underlying physiology, preparation, and postintubation management. Those with high-risk features including trauma, elevated intracranial pressure, upper gastrointestinal bleed, cardiac tamponade, aortic stenosis, morbid obesity, and pregnancy must be managed with airway expertise.Conclusions: This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician. [ABSTRACT FROM AUTHOR]

Background: Successful airway management is critical to the practice of emergency medicine. Emergency physicians must be ready to optimize and prepare for airway management in critically ill patients with a wide range of physiologic challenges. Challenges in airway management commonly encountered in the emergency department are discussed using a pearl and pitfall discussion in this first part of a 2-part series.Objective: This narrative review presents an evidence-based approach to airway and patient management during endotracheal intubation in challenging cases that are commonly encountered in the emergency department.Discussion: Adverse events during emergent airway management are common, with postintubation cardiac arrest reported in as many as 1 in 25 intubations. Many of these adverse events can be avoided with the proper identification and understanding of the underlying physiology, preparation, and postintubation management. Patients with high-risk features including severe metabolic acidosis; shock and hypotension; obstructive lung disease; pulmonary hypertension, right ventricle failure, and pulmonary embolism; and severe hypoxemia must be managed with airway expertise.Conclusions: This narrative review discusses the pearls and pitfalls of commonly encountered physiologic high-risk intubations with a focus on the emergency clinician. [ABSTRACT FROM AUTHOR]

Background: Hemophilia and von Willebrand disease (VWD) are the most common congenital coagulation factor deficiencies. Patients with these disorders who experience bleeding complications are often initially managed in the emergency department (ED).Objective Of the Review: This review will focus on the emergency department management of patients with these disorders and provide an update on current treatment options.Discussion: The mainstay of management is initial stabilization, control of bleeding when possible, and administration of specific factors. Early coordination of care with hematology is critical.Conclusions: Emergency medicine providers must have an understanding of the pathophysiology, clinical presentation, and management strategies in order to optimally care for these complex patients. [ABSTRACT FROM AUTHOR]

Planning for clerkships in emergency medicine (EM) can be stressful, prolonged, and challenging. Therefore, medical students should start planning for them early. In this article, we offer guidance regarding several issues pertinent to the EM clerkship, such as the best time to schedule one (or more) during medical school, the most appropriate institution or program to schedule it, the process of selecting and applying for the clerkship, and the number of EM clerkships to consider. We will explain why an EM clerkship should be scheduled between June and October and the reason that 2 EM clerkships at different sites are sufficient for the majority of students. Additionally, we emphasize that clerkships in emergency departments associated with EM residency programs or with reputations for outstanding student teaching tend to be most beneficial. Above all, students interested in EM should attempt to leave a great impression after completing their clerkships by providing stellar patient care, demonstrating enthusiasm at all times, and maintaining professionalism. In turn, they will gain knowledge and clinical experiences that should prove valuable in their future. [ABSTRACT FROM AUTHOR]

Background: Emergency patient presentations with febrile neutropenia are a heterogeneous group. A small minority of these patients proceed to develop significant medical complications. Risk stratification using scores, such as the Multinational Association for Supportive Care in Cancer score, have been advocated to identify patients who are at low risk of adverse outcome suitable for treatment on an ambulatory care pathway.Objectives: We sought to report the experience of 100 patients presenting acutely with neutropenic fever managed in an emergency ambulatory fashion.Methods: Patients presenting as an emergency with low-risk febrile neutropenia managed in an ambulatory setting between January 2017 and February 2019 at a tertiary cancer hospital in England were prospectively studied. Patients with a fever >38.0°C and an absolute neutrophil count <1.0 × 109/L were included. All patients with a Multinational Association for Supportive Care in Cancer score ≥21 and a National Early Warning Score ≤3 were potentially eligible for the pathway. Complications were classified as serious if the patient developed persistent hypotension, respiratory failure, intensive care unit admission, altered mental status, disseminated intravascular coagulation, renal failure requiring renal replacement therapy, electrocardiogram changes requiring antidysrhythmic treatment, and 30-day mortality.Results: One hundred patients with low-risk febrile neutropenia consecutively managed in an emergency ambulatory fashion were prospectively analyzed. Eighty-one patients were female and the median age was 51 y (range 17-79 y). No patients developed serious complications. Eight (8% [95% confidence interval 4.1-15.0%]) patients had a 7-day readmission.Conclusion: Outpatient ambulatory care for emergency patients with low-risk febrile neutropenia can be delivered in a safe and effective fashion. Collaboration between acute care physicians and oncologists is required to develop local models based on national guidelines to facilitate individualised care for emergency oncology patients. [ABSTRACT FROM AUTHOR]

Background: Neurofibromatosis type 1 (NF1) is generally a benign disease but has the potential for rare and fatal complications. Vascular signs and symptoms associated with NF1 are reported in only 1-3% of patients. Pulmonary complications have been rarely described in the literature and spontaneous rupture of a major thoracic artery is, however, extremely uncommon.Case Report: We report the case of a patient with NF1 admitted to the emergency department for the management of a spontaneous life-threatening left hemothorax. The patient became hemodynamically unstable after thoracic drainage. Computed tomography angiography revealed extravasation at the level of the eighth intercostal artery. Digital angiography showed an intercostal aneurysm. Catheterization of the eighth intercostal artery was unsuccessful and an open surgery was finally performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We highlight the importance of recognizing that patients with a benign disease like NF1 may present to the emergency department with a spontaneous life-threatening hemothorax. Immediate transfer for embolization is not always the best treatment management but thoracotomy is preferred in unstable patients. [ABSTRACT FROM AUTHOR]

The Match is a daunting process for everyone, but it can be exceedingly more complicated for couples. Accordingly, the Couples Match was introduced by the National Residency Match Program in 1984 and has been witnessing a steady increase in the number of participating couples over the past 30 years. The highest number of couples participating in the match, and the highest match rate among them, was recorded in 2018. In this article, we provide couples considering the Couples Match, with one or both partners planning to apply to emergency medicine, with insights on this process. Although it may initially appear to be complicated, the Couples Match enables partners to obtain postgraduate training in geographic proximity to one another. With good communication between the partners and their advisors, an exciting joint venture can unfold that is fueled by the strength of the couple. [ABSTRACT FROM AUTHOR]

Background: Hypertensive urgency is a clinical scenario that may be associated with herbal supplement use and that requires special consideration with regard to emergency department management.Case Report: A 49-year-old man presented to the emergency department with palpitations and severely elevated blood pressure without evidence of end organ dysfunction. Hypertension failed to be controlled with multiple doses of oral clonidine and intravenous labetalol. The patient later admitted to using an herbal supplement containing yohimbine, a selective ⍺2-adrenoreceptor antagonist specifically linked to cases of refractory hypertension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Between 17-35% of the U.S. adult population may use herbal supplements on a sporadic or regular basis; pharmacologically active agents in herbal supplements may affect both a patient's presentation and response to treatment. Most patients do not mention over-the-counter and herbal products in their medication profile unless specifically asked, and therefore it is important for emergency physicians to be aware of the pharmacologic effects of herbal supplements in the evaluation and treatment of refractory severe hypertension. [ABSTRACT FROM AUTHOR]

Background: A thunderclap headache (TCH) is a severe headache reaching at least 7 (out of 10) in intensity within 1 min of onset, and can be the presenting symptom of several conditions with potential for significant morbidity and mortality.Objective Of the Review: This narrative review evaluates the various conditions that may present with TCH and proposes a diagnostic algorithm for patients with TCH.Discussion: TCH is a symptom associated with several significant diseases. The most common diagnosed condition is subarachnoid hemorrhage (SAH). Other diagnoses include reversible cerebral vasoconstriction syndrome, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, spontaneous intracranial hypotension, and several others. Patients with TCH require history and physical examination, with a focus on the neurologic system, evaluating for these conditions, including SAH. Further testing often includes head computed tomography (CT) without contrast, CT angiography of the head and neck, and lumbar puncture. Evaluation must take into account history, examination, and the presence of any red flags or signs suggestive of a specific etiology. An algorithm is provided for guidance within this review incorporating these modalities. Management focuses on the specific diagnosis. If testing is negative for a serious condition and the patient improves, discharge home may be appropriate with follow-up.Conclusions: Patients presenting with TCH require diagnostic evaluation. History and examination are vital in assessing for risk factors for various conditions. Focused testing can assist with diagnosis, with management tailored to the specific diagnosis. [ABSTRACT FROM AUTHOR]

Background: Most pediatric resuscitator bags are equipped with a positive-pressure relief ("pop-off") valve meant to prevent delivery of excessive pressure. Pop-off valves, however, can lead to adverse events in emergency situations when providers are unaware of their significance.Case Report: A 3-year-old girl with muscular atrophy and a chronic tracheostomy tube was noted to have decreasing oxygen saturations. Paramedics found the patient in cardiac arrest and initiated resuscitative efforts; the patient regained pulses but quickly became pulseless again. There were two more cycles of cardiac arrest followed by return of spontaneous circulation. When she arrived at the emergency department pulses were present. The emergency physician performed bag ventilation and felt no resistance to bag squeezing, but saw no chest rise, and realized the patient was not being ventilated because all of the air was escaping through the pop-off valve. When the valve was closed, it was impossible to perform bag ventilation. She was found to have complete occlusion of her tracheostomy tube; the paramedics had not been ventilating during transport, though were unaware of the occlusion because of the open pop-off valve. Removal of the tracheostomy tube and placement of an endotracheal tube significantly improved ventilation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pop-off valves are common on pediatric resuscitator bags, but often result in insufficient ventilation and oxygenation during emergency airway management. Emergency airway experts recommend that pop-off valves be avoided or deactivated during emergency resuscitation, but this information has not been widely disseminated. [ABSTRACT FROM AUTHOR]

Background: Zipper injuries are rare in the pediatric emergency department, with most reported cases involving the penile and scrotal skin. Knowledge of appropriate zipper release techniques is important to ensure safe and immediate removal of entrapped tissue to prevent complications.Case Report: This case report describes a unique presentation of a zipper injury involving entrapment of the upper eyelid. We describe the successful removal of the zipper with gentle manipulation aided by mineral oil lubrication and by cutting fabric from the zipper system to release tension. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: While zipper injuries are rare, an emergency physician must be prepared to provide urgent intervention to prevent complications. This unique case report presents 1 example of successful zipper release in the case of a zipper injury to the eyelid in a child. We review other approaches for emergent zipper removal and discuss postprocedure care. [ABSTRACT FROM AUTHOR]

Background: Urgent care centers (UCCs) can offer a cheap alternative to emergency departments (EDs) for some patients with acute complaints. However, if patients who initially present to a UCC are unnecessarily transferred to an ED, those patients may suffer undue financial harm. The group of patients transferred from UCCs to EDs have never previously been studied.Objectives: The primary objective of this study was to determine the fraction of transfers from a UCC to an ED that were unnecessary. We also assessed the frequency with which these patients were discharged from the ED, and tried to determine which groups of patients were most likely to be unnecessarily transferred.Methods: This was a retrospective chart review performed on patients transferred from UCCs to our ED. If the transferred patient had no advanced imaging tests, advanced procedures, or specialty consultations in the ED, and was not admitted, we considered the transfer to be unnecessary. Patients were stratified by age (adult vs. pediatric) and type of insurance.Results: We identified 3232 patients who were transferred from UCCs to our ED over a 1-year period. Among those, 1159 (35.9%; 95% confidence interval [CI] 34.2-37.5%) met our criteria as unnecessary, and 2075 (64.2%; 95% CI 62.5-65.8%) were discharged from the ED. Notably, pediatric patients were more likely than adult patients to be unnecessarily transferred. Patients without medical insurance were not more likely to be transferred than those with private insurance.Conclusion: Most patients transferred to our ED from a UCC were discharged, and many transfers were unnecessary, especially those involving pediatric patients. These transfers may represent an economic burden to our society. [ABSTRACT FROM AUTHOR]

Background: Emergency medicine personnel frequently respond to major disasters. They expect to have an effective and efficient management system to elegantly allocate available resources. Despite claims to the contrary, experience demonstrates this rarely occurs.Objectives: This article describes privatizing disaster assessment using a single-purposed, accountable, and well-trained organization. The goal is to achieve elegant disaster assessment, rather than repeatedly exhorting existing groups to do it.Discussion: The Rapid Disaster Evaluation System (RaDES) would quickly and efficiently assess a postdisaster population's needs. It would use an accountable nongovernmental agency's teams with maximal training, mobility, and flexibility. Designed to augment the Inter-Agency Standing Committee's 2015 Emergency Response Preparedness Plan, RaDES would provide the initial information needed to avoid haphazard and overlapping disaster responses. Rapidly deployed teams would gather information from multiple sources and continually communicate those findings to their base, which would then disseminate them to disaster coordinators in a concise, coherent, and transparent way.Conclusions: The RaDES concept represents an elegant, minimally bureaucratic, and effective rapid response to major disasters. However, its implementation faces logistical, funding, and political obstacles. Developing and maintaining RaDES would require significant funding and political commitment to coordinate the numerous agencies that claim to be performing the same tasks. Although simulations can demonstrate efficacy and deficiencies, only field tests will demonstrate RaDES' power to improve interagency coordination and decrease the cost of major disaster response. At the least, the RaDES concept should serve as a model for discussing how to practicably improve our current chaotic disaster responses. [ABSTRACT FROM AUTHOR]

Background: Ondansetron is often used in the emergency department (ED) to promote oral rehydration in children with acute gastroenteritis (AGE), yet medication solutions administered orally may be poorly tolerated in this population.Objectives: We compared the tolerability of ondansetron oral dissolve tab (ODT) to oral solution (OS) in children presenting to the ED with AGE.Methods: Using alternate-day controlled clinical trial design, children aged 3 months to 10 years received either ondansetron ODT or OS. Our primary outcome was early vomiting (within 15 min of drug administration). The secondary outcome was intravenous (i.v.) fluid administration.Results: There were 462/534 eligible children who met study criteria. Demographics, severity, and duration of illness were similar between groups. Using intention-to-treat analysis, early vomiting occurred in 8/209 ODT vs. 19/253 OS children (3.8% vs. 7.5%; odds ratio [OR] 0.49; 95% confidence interval [CI] 0.18-1.21). Using as-treated analysis, 6/222 (2.7%) children receiving ODT experienced early vomiting, compared with 21/221 (9.5%) of the OS group (OR 0.26; 95% CI 0.09-0.70). The proportion of children discharged without i.v. fluids was not different (intention-to-treat: ODT = 91.4% (191/209), OS = 94.1% (238/253), OR 1.49, 95% CI 0.69-3.28; as-treated: ODT = 92.3% (205/222), OS = 93.2% (206/221), OR 0.88, 95% CI 0.40-1.93).Conclusions: Using a conservative intention-to-treat analysis, we found that children presenting to an ED with AGE did not have statistically less early vomiting with ondansetron ODT as compared with OS. However, our as-treated analysis demonstrates that children receiving ondansetron ODT experienced early vomiting approximately one-third as often as those receiving OS. The rate of i.v. fluid administration was no different between groups regardless of the type of analysis used. [ABSTRACT FROM AUTHOR]

Abstract: Background: Orally administered anticoagulants that offer alternatives to warfarin have been developed in recent years and are currently available for reduction of stroke risk in patients with non-valvular atrial fibrillation, the prophylaxis of venous thromboembolism after hip or knee replacement surgery, and the treatment and secondary risk reduction of deep vein thrombosis and pulmonary embolism. Objectives: This article will provide a brief introduction to these new oral anticoagulants and then review the approaches that can be taken for the emergency management of hemostasis in patients bleeding or at risk for bleeding while receiving warfarin or one of two newer agents, the direct thrombin inhibitor dabigatran or the factor Xa inhibitor rivaroxaban. Discussion: Oral anticoagulant use is widespread and likely to continue to increase. Warfarin has been the standard of care in oral anticoagulation for many years; its bleeding risks are well known and associated emergency protocols are well established. As newer oral anticoagulants become more widely used, similar procedures will need to be developed. Although there are as yet no specific reversal agents for these newer drugs, recommendations for overdose, emergency hemostasis, and preoperative management are available. Further, while the newer agents do not require routine coagulation monitoring, assays for use in non-routine situations are being explored. Conclusions: The introduction of alternative oral anticoagulants will require emergency procedures that differ in some respects from those currently in place for warfarin and it will be necessary for Emergency Medicine professionals to become familiar with these procedures. Clinical stabilization of the bleeding or at-risk patient remains the emergency physician’s priority. [Copyright &y& Elsevier]

Abstract: Background: Information obtained from vehicle crash scenes, called kinematics, may prove useful in the management of victims and may complement anatomical and physiological findings. Objectives: In addition to analyzing the significance of age, gender, position occupied in the vehicle, the use of restraint systems, and ejection from the vehicle, the objective was to carry out a preliminary study of what we have defined as the Structural Deformity Index (SDI) to verify its usefulness in predicting injury severity at the scene of a motor vehicle crash. The index consists of various parameters that can be easily identified at the crash scene. Method: An historical cohort of vehicle occupants involved in crashes in the Navarra province of Spain from January 1, 2001 to December 31, 2002 was studied. Information was collected from the database of the Navarra Severe Trauma Victim group study. Bivariate statistical analysis and multivariate logistic regression models were employed for statistical management. Results: There were 212 vehicle occupants identified. Significant differences in severity of injury, and of mortality, were observed based on age, ejection from the vehicle, and a high SDI. Logistic regression showed significant differences in injury severity by age (odds ratio [OR] 6.55, 95% confidence interval [CI] 1.6–26.7) and high SDI (OR 1.84, 95% CI 1–3.3), as well as differences in the patient death rate by age (OR 6.92, 95% CI 1.2–38.9) and high SDI (OR 3.28, 95% CI 1.5–6.8). Conclusions: The SDI is useful to the first responders, enabling them to alert and transmit objective, reliable information to the emergency coordination center, thus efficiently activating health care resources. In addition, use of the SDI may assist prehospital and hospital health care providers to suspect the presence of particular serious injuries when anatomical and physiological criteria are not definitive. [Copyright &y& Elsevier]

Abstract: Background: Pulmonary embolism (PE), an uncommon diagnosis in pediatric patients, is a potentially life-threatening condition with significant morbidity and mortality. Improvements in pediatric care have resulted in survival of more chronically and critically ill children and thus, an increased number of pediatric patients at risk for this disease. Objectives: We review the pathophysiology, risk factors, presentation, diagnosis, and initial management of PE in pediatric patients presenting to the Emergency Department. Discussion: Although there is a significant lack of pediatric-specific literature pertaining to the diagnosis and management of PE, there are clear differences in the emergency approach to these patients, including specific risk factors and the inutility of clinical decision rules and D-dimer. Conclusion/Summary: We outline these differences and present rational diagnostic and treatment algorithms. [Copyright &y& Elsevier]

Abstract: In May 2003, the TOPOFF 2 national disaster drill demonstrated inadequate preparedness for mass casualty terrorist events and failed to address the willingness of Emergency Department (ED) personnel to assist with these events. The objective of this study was to examine ED personnel willingness to respond to various multiple casualty events. A prospective voluntary survey of ED personnel from multiple hospitals was randomly administered in the form of vignette-based questionnaires. The survey of 204 participants at eight hospitals in the Chicago area revealed that staff members were more willing to work additional hours for victims of an airplane crash (98.0%), than for a radioactive bomb (85.3%), or a biologic agent (54.0%). For the biologic agent only, men were significantly more likely to respond than women. Hospital management should anticipate significant reductions in workforce during biologic and radioactive disaster events. Employees'' willingness to respond was not augmented by any incentives offered by hospitals, although enhanced financial remuneration and disability coverage showed the most potential to increase response. [Copyright &y& Elsevier]

Abstract: Pain is one of the most prevalent conditions treated by Emergency Physicians, although it remains contested how to interpret, measure, and treat this condition. In particular, there is controversy over how to identify and treat patients with chronic under-treated pain and those who are potentially malingering (drug-seeking). This article discusses currently accepted paradigms for treating potentially malingering patients, difficulties some communities may have when these paradigms are applied, and the results of implementing pain treatment guidelines that limit opioid use. Systematically limiting opioids via these guidelines was not associated with a decrease in overall patient satisfaction, patient satisfaction with pain management, overall volume, or volume of patients with potential drug-seeking diagnoses. Emergency Physicians’ perception of quality of care delivered, as well as job satisfaction, increased after implementation of the guidelines. [Copyright &y& Elsevier]

Abstract: We analyzed the impact of three consecutive hurricanes in 2004 on two central Florida Emergency Department (ED) patient volumes and types of presentations. Data were extracted from the hospital database and compared to the previous year. At both EDs visits dropped significantly on the day of all three hurricanes compared to 2003. The decrease in patient volume was even greater during the second and third hurricane compared to the first one. Once weather conditions improved, a dramatic rise in patient census was noted. During the aftermath of the first hurricane a significantly higher number of patients with injuries and carbon monoxide (CO) intoxications was seen, as well as ED visits due to lack of oxygen, electricity or hemodialysis. During the aftermath of a hurricane, EDs should be staffed and equipped to treat greater numbers of patients with acute injuries. [Copyright &y& Elsevier]

Abstract: To aid disaster planning, a retrospective review of patients seen by New Mexico 1 Disaster Medical Assistance Team (NM-1 DMAT) after four disasters was conducted. Data analyzed included age, gender, past medical history, chief complaint, diagnosis, diagnostic testing, treatment, triage category, disposition, and time to presentation after the disaster. Data were analyzed for differences between patients presenting early vs. late after a disaster and to test if availability of diagnostic testing changed patient disposition. The results showed that the majority of patients presented with upper respiratory tract infection symptoms, wounds, and musculoskeletal pain. The needs of patients were similar whether they presented early or late. The same proportion of patients was transferred to hospitals when diagnostic testing was available vs. not available, despite a higher level of acuity when diagnostic testing was available. In conclusion, DMATs should be prepared to see high volumes of low acuity patients. Patient needs do not change with time. Diagnostic testing may be useful. [Copyright &y& Elsevier]

Abstract: We sought to describe the implementation of the Hospital Emergency Incident Command System (HEICS) at National Cheng Kung University Hospital (NCKUH) in Taiwan, ROC during the outbreak of severe acute respiratory syndrome (SARS) in early 2003. We administered a 14-question survey via structured interviews to individuals occupying activated HEICS leadership positions at NCKUH to identify the organization, structure, and function of the HEICS units and subunits they led and the job actions they performed from 25 March to 16 June 2003 Thirty-three of 38 persons (87%) occupying 39 of 44 (89%) activated HEICS leadership positions directly participated in the survey. The participants collectively reported: 1) the creation of four new HEICS unit leader positions and corresponding units during the outbreak, including the infection control officer (administrative section) and SARS assessment, isolation, and critical care unit leaders (operations section); 2) the creation of six new HEICS subunits, including functional areas for fever screening, SARS assessment, and resuscitation outside the hospital, and SARS patient care, SARS critical care, and employee isolation inside the hospital; and 3) the performance of new job actions related to infection control by all HEICS unit leaders. HEICS provides a flexible framework that seems to have assisted NCKUH in the organization of its emergency response to the SARS outbreak in Taiwan, ROC. [Copyright &y& Elsevier]

Dopamine D2 antagonists are known to induce akathisia, the emergency management of which remains undetermined. We sought to evaluate the effectiveness of diphenhydramine in the treatment of akathisia induced by 10 mg intravenous prochlorperazine. This prospective, open-label, uncontrolled study evaluated a cohort of akathisic adult Emergency Department patients who were participating in a series of three studies of acute akathisia at an academic medical center. Each subject received intravenous diphenhydramine, with akathisia measurements (graded from 0–17 points) performed just before and 30 min after infusion. Mean scores were calculated using descriptive statistical analyses. The effect of treatment was evaluated using the paired t-test. For the 87 akathisic patients, the mean score before treatment was 9.8 ± 3.6, and after treatment was 1.2 ± 2.6, a mean reduction of 8.5 ± 3.8 (95% confidence interval [CI], 7.8 to 9.4; p < 0.0001). In conclusion, intravenous diphenhydramine rapidly reduces signs and symptoms of acute akathisia induced by prochlorperazine. [Copyright &y& Elsevier]

Abstract: Background: Abdominal pain is an uncommon presentation of lead toxicity in the emergency department (ED). However, making the diagnosis is important in avoiding unnecessary testing and the long-term sequelae of lead toxicity. Objectives: To illustrate possible presentations of abdominal pain secondary to lead toxicity and highlight the importance of taking a thorough patient history. Case Report: We report 2 patients who presented to the ED with abdominal pain and underwent extensive evaluations that did not reveal an etiology. At follow-up visits, their occupational histories revealed possible lead exposures from working for a bullet-recycling company. Tests revealed that each patient had extremely high lead levels and they were both treated for lead toxicity. Their abdominal pain resolved as their lead levels decreased. Conclusion: These cases demonstrate a rare but significant cause of abdominal pain in the ED. Although history-taking in the ED is necessarily brief, these cases underscore the importance of obtaining an occupational history. [Copyright &y& Elsevier]

Abstract: Background: Urgent decisions in the Emergency Department allow for only a short history and physical examination. Objectives: To highlight the risks associated with a strict application of protocols, especially in the emergency setting. Case Report: An unusual case of acute dysarthria is presented. Conclusion: Even in the emergency setting, thorough history-taking and physical examination remain fundamental, and it is necessary to “think outside the box.” [Copyright &y& Elsevier]

Abstract: Background: The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch (EMD) system that is widely used to prioritize 9-1-1 calls and optimize resource allocation. MPDS is a computer-based EMD system that uses callers'' responses to scripted questions to categorize cases into groups and subgroups, based on complaint and perceived acuity. Objective: This study evaluates the ability of MPDS codes to predict prehospital use of medications. Methods: All transported prehospital patients assigned a subgroup by MPDS from January 1, 2009 to December 31, 2009 in a diverse urban community were matched with their prehospital electronic patient care records. The records of transported patients dispatched through EMD were queried for prehospital interventions and matched to their MPDS classifications. Only MPDS subgroups with 10 or more calls were included in the analysis. Results: A total of 38,005 patients met inclusion criteria. Patients with chest pain, breathing problems, heart problems, and diabetic problems received the most medications. Medications were administered in 19% of all calls. The individual MPDS subgroup with the highest rate of medication administration was 6E1A (breathing problems, 76%). Higher rates of Advanced Life Support (ALS) interventions in higher-acuity categories (e.g., Alpha, Bravo, Charlie) were seen in several EMD categories, including unconscious/fainting, breathing problems, and abdominal pain; but this was not observed in many other categories, including seizure, sick person, traumatic injury, and hemorrhage/lacerations. Conclusions: Medications were administered in 19% of all calls. There were higher rates of ALS interventions in higher-acuity categories that were not observed in many other categories. [Copyright &y& Elsevier]