Barry Hahn

Do Hemolyzed Potassium Specimens Need to be Repeated

BACKGROUND In the emergency department (ED), hyperkalemia in the presence of hemolysis is common. Elevated hemolyzed potassium levels are often repeated by emergency physicians to confirm pseudohyperkalemia and to exclude a life-threatening true hyperkalemia. OBJECTIVES We hypothesize that in patients with a normal renal function, elevated hemolyzed potassium, and normal electrocardiogram (ECG), there may not be a need for further treatment or repeat testing and increased length of stay. METHODS Data were prospectively enrolled patients presenting to the ED from July 2011 to February 2012. All adult subjects who had a hemolyzed potassium level ≥ 5.5 mEq/dL underwent a repeat potassium level and ECG. The incidence of true hyperkalemia in this population was measured. RESULTS A total of 45 patients were enrolled. The overall median age was 52 years (range 25-83 years); 22 were female (49%). In patients with hyperkalemia on initial blood draw and glomerular filtration rate (GFR) ≥ 60 (n = 45), the negative predictive value was 97.8% (95% confidence interval [CI] 88.2-99.9%). When patients had hyperkalemia on initial blood draw, GFR ≥ 60, and a normal ECG (n = 42), the negative predictive value was 100% (95% CI 93.1-100%). CONCLUSIONS In the setting of hemolysis, GFR ≥ 60 mL/min in conjunction with a normal ECG is a reliable predictor of pseudohyperkalemia and may eliminate the need for repeat testing. In patients with a normal GFR who are otherwise deemed safe for discharge, our results indicate there is no need for repeat testing.

Pericardial effusion and pneumothorax after breast augmentation.

This is a case of a 41-year-old woman who presented with near-syncope and generalized weakness 1 week after breast augmentation. The patient was diagnosed in the Emergency Department (ED) with a pneumothorax and pericardial effusion. Although post-breast augmentation pneumothorax is well documented in the plastic surgery literature, to our knowledge the complication of pericardial effusion has not been reported. It is important to be aware of this potential morbidity associated with breast augmentation, an increasingly popular elective procedure.

PILOT STUDY ON DOCUMENTATION SKILLS: IS THERE ADEQUATE TRAINING IN EMERGENCY MEDICINE RESIDENCY?

BACKGROUND Thorough and accurate documentation in the medical record is important, and documentation skills should be an integral component of emergency medicine (EM) residency training. STUDY OBJECTIVE We sought to study the documentation skills of EM residents as they relate to emergency department (ED) reimbursement. METHODS This was a retrospective, cross-sectional study. We reviewed all charts of patients presenting to the adult ED during a 2-week period. We compared three groups: patients seen primarily by an EM resident, patients seen primarily by a physician assistant (PA), and patients seen primarily by an attending emergency physician. Outcome measures were the incidence of downcodes and dollars lost to downcodes in all groups. RESULTS There were 212 patients in the resident group, 683 patients in the PA group, and 437 patients in the attending group. There were 12 downcodes (5.7%, 95% confidence interval [CI] 2.96-9.70) in the resident group, 10 downcodes (1.5%, 95% CI 0.70-2.68) in the PA group, and 17 downcodes (3.9%, 95% CI 2.28-6.14) in the attending group (p = 0.002). The mean dollar lost per patient seen in the resident group was

Temporary Nerve Block at Selected Digits Revealed Hand Motor Deficits in Grasping Tasks

3.21 (95% CI 1.41-5.00);

Incidence and pathology of repeat computed tomography of the abdomen and pelvis in a pediatric emergency department population.

0.91 (95% CI 0.33-1.49) in the PA group; and

The quick sequential organ failure assessment (qSOFA) identifies septic patients in the out-of-hospital setting

2.23 (95% CI 1.17-3.28) in the attending group (p = 0.002). CONCLUSION Charts documented primarily by EM residents were more likely to be downcoded than charts documented primarily by PAs or ED attendings. This downcode rate resulted in a greater loss of revenue in the resident group. We believe this represents an area for improvement in EM residency education.

Does a normal screening ultrasound of the abdominal aorta reduce the likelihood of rupture in emergency department patients

Peripheral sensory feedback plays a crucial role in ensuring correct motor execution throughout hand grasp control. Previous studies utilized local anesthesia to deprive somatosensory feedback in the digits or hand, observations included sensorimotor deficits at both corticospinal and peripheral levels. However, the questions of how the disturbed and intact sensory input integrate and interact with each other to assist the motor program execution, and whether the motor coordination based on motor output variability between affected and non-affected elements (e.g., digits) becomes interfered by the local sensory deficiency, have not been answered. The current study aims to investigate the effect of peripheral deafferentation through digital nerve blocks at selective digits on motor performance and motor coordination in grasp control. Our results suggested that the absence of somatosensory information induced motor deficits in hand grasp control, as evidenced by reduced maximal force production ability in both local and non-local digits, impairment of force and moment control during object lift and hold, and attenuated motor synergies in stabilizing task performance variables, namely the tangential force and moment of force. These findings implied that individual sensory input is shared across all the digits and the disturbed signal from local sensory channel(s) has a more comprehensive impact on the process of the motor output execution in the sensorimotor integration process. Additionally, a feedback control mechanism with a sensation-based component resides in the formation process for the motor covariation structure.

Should Osteopathic Students Applying to Allopathic Emergency Medicine Programs Take the USMLE Exam

Objectives Computed tomographic (CT) scanning is increasingly prevalent in emergency departments (EDs). It is a moderate- to high-radiation diagnostic technique that exposes more than 1 million children per year to unnecessary radiation. Repeat CT of the abdomen and pelvis (CTAP) among pediatric patients who return to the ED within 1 year may be an example of unnecessary pediatric radiation exposure. The objectives of this study were to identify the incidence of pediatric patients who undergo more than 1 CTAP within 1 year and to detect the incidence of significant pathology on these repeat scans. Methods This was a retrospective review of subjects younger than 18 years with an initial CTAP as an ED patient, inpatient, or outpatient and a second CTAP within 12 months and during an ED visit. Results During the observation period, 172 pediatric ED admissions had at least 1 repeat admission involving an abdominal CT scan. Thirty-seven of the CT scans (19.3%) were positive. Sixty percent of the positive cases (n = 22) were attributable to the 3 most prevalent diagnoses: appendicitis in 8 cases (21.6%), kidney stone in 8 cases (21.6%), and colitis in 6 cases (16.2%). Approximately, one third of repeat CT scans occurred within the first month of the initial CT scan, and two thirds occurred within 6 months of the initial CT scan. Conclusions A substantial percentage of pediatric patients undergo more than 1 CTAP within a 1-year time frame. Among these patients, a large portion were diagnosed significant pathology.

Acute Wharton's Duct Sialadenitis and Submandibular Infection

Background Recently a multispecialty, multinational task force convened to redefine the criteria for organ dysfunction, sepsis, severe sepsis, and septic shock. The study recommended the quick sequential organ failure assessment (qSOFA) score to identify sepsis patients. The qSOFA is felt to be the initial screen to prompt a more in‐depth sepsis workup. This may be particularly true in resource‐limited environments such as the prehospital arena. Objectives The goal of this study was to identify whether emergency medical services (EMS) patients who met all three qSOFA criteria correlated with an emergency department (ED) identification of sepsis. Methods This was a retrospective chart review of adult patients ≥ 18 years of age, meeting qSOFA criteria and presenting to the emergency department between 1/01/2014 and 6/30/2016. Subjects were identified through an electronic query of the EMS record repository. Results 72 subjects were included in the final analysis. Subjects in the septic group tended to be older with a mean age of 72 years vs 64 years. There was no observed discrepancy relating to gender. 48 of the subjects (67%) were identified as septic and 24 (33%) were identified as non‐septic after review of the ED chart. This yielded a positive predictive value of the prehospital qSOFA as 66.67% (95% CI 55.8–77.6). Conclusions EMS patients with positive qSOFA screens were more likely to be septic upon disposition to the ED.

A Novel Approach to Addressing an Unintended Consequence of Direct to Room: The Delay of Initial Vital Signs

INTRODUCTION Abdominal aortic aneurysm (AAA) development is a multifactorial process that is more prevalent among people ≥65years of age. Major risk factors are obesity, male sex, history of smoking (at least 100 cigarettes in a persons lifetime), and history of AAA in a first-degree relative. The United States Preventative Task Force has recommended a one-time ultrasound screening for men aged 65-75years. Based on studies, negative results on a single ultrasound examination around the age of 65years appear to virtually exclude the risk for future AAA rupture or death. While ultrasonography (US) is the confirmatory study of choice, computed tomography (CT) can also be used in the diagnosis of AAA. The goal of this study is to determine if AAA rupture can reliably be excluded in individuals with abdominal pain who have had a normal caliber aorta on CT or US after the age of 65years. MATERIALS AND METHODS A retrospective study (approved by institutional review board) of emergency department (ED) patients in an urban academic center was performed. Subjects were included if they met the following criteria: age ≥65years; an initial CT or US as an ED patient, inpatient, or outpatient for any indication, which identified an abdominal aorta <3cm; and a second CT or US during an ED visit. The incidence of ruptured AAA on the second CT or US with a history of normal aortic caliber was identified. RESULTS During the study period, 606 subjects were enrolled. Demographic data are listed in Table 1. Three subjects (0.5%) exhibited an abnormal-sized aorta on ED evaluation. None of these three subjects had an AAA intervention. The average size of the abnormal aorta in these three subjects was 3.3cm (S.D. 0.17). CONCLUSION Based on these results, it appears that AAA and rupture may reliably be excluded in ED patients with abdominal pain who have previously had a normal caliber aorta on CT or US after the age of 65years. A prospective, multicenter study would help validate these findings.