David C. Pigott

Hemorrhagic Fever Viruses

This article reviews the epidemiology, pathophysiology, and clinical management of patients with suspected or confirmed viral hemorrhagic fever infection. The focus is on clinical management based on case series from naturally occuring outbreaks of viral hemorrhagic fever infection as well as imported cases of viral hemorrhagic fever encountered in industrialized nations. The potential risk of bioterrorism involving these agents is discussed as well as emergency department and critical care management of isolated cases or larger outbreaks. Important aspects of management, including recognition of infected patients, isolation and decontamination procedures, as well as available vaccines and therapies are emphasized.

Prevalence and factors associated with gonorrhea and chlamydial infection in at-risk females presenting to an urban emergency department.

Background Patients without a regular healthcare source are less likely to be tested, diagnosed, and treated effectively for sexually transmitted diseases (STDs). Emergency departments (EDs) are a major healthcare source for patients without health insurance or primary care providers. Goal This study evaluated the prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae in women aged 15 to 35 years presenting to a metropolitan ED with genitourinary or pregnancy-related complaints and the frequency with which patients were effectively treated for these infections during routine ED care. Study Design Women completed an interviewer-administered questionnaire and submitted urine for ligase chain reaction (LCR) testing for C trachomatis and N gonorrhoeae. Results The combined prevalence of gonorrhea and chlamydia was 16.4% (n = 62), and factors associated with infection included younger age and greater numbers of sex partners over 30 days. Problem-oriented care failed to detect infection in most cases, and 58% of infected women left the ED without effective therapy. Through a close working relationship with the local health department, we documented that 92% had received effective follow-up therapy. Conclusion Continued efforts to refine and develop tools for the diagnosis and management of cervical infections for at-risk women seen in EDs are warranted.

Emergency department evaluation of the febrile traveler

Summary The emergency department evaluation of the febrile traveler presents the emergency physician with a set of unique and often challenging circumstances. In addition to evaluating and managing the usual array of community-acquired infections, the clinician must be prepared to diagnose and treat a host of uncommon and potentially life-threatening pathogens. This diseases range from widespread tropical diseases such as malaria to the more exotic and lethal viral hemorrhagic fevers. A thoughtful approach guided by geographic patterns of illness offers a reliable method for determining the most likely sources of fever in the returned traveler as well as a focused diagnostic and treatment strategy.

Ability of pediatric emergency medicine physicians to identify anatomic landmarks with the assistance of ultrasound prior to lumbar puncture in a simulated obese model.

Objectives Lumbar punctures (LPs) are typically performed using anatomical surface landmarks. However, as body mass index increases, identifying surface landmarks becomes more difficult. Ultrasound has been proposed as a tool for identifying these landmarks prior to LP. This study evaluates the effectiveness of a brief training program in ultrasound identification of anatomical landmarks in a simulated obese model prior to completing an LP. Methods Pediatric emergency medicine physicians completed a pretest questionnaire on ultrasound familiarity prior to an educational session. Participants utilized ultrasonography without the assistance of palpation on a simulation LP model saving images for review. Participants attempted LP on phantom models with simulated body mass indices of 35 and 40 kg/m2. Time to image acquisition and successful aspiration of cerebrospinal fluid from the model were recorded. Two expert sonologists independently reviewed all images for correct landmark identification. Results Seven of the 19 participants had previous familiarity with ultrasound. The mean time to lumbar image acquisition significantly improved for all individuals from 176 seconds to 100 seconds (P = 0.003). Comfort level with ultrasound improved (P < 0.001) as well as comfort level in performing a lumbar ultrasound (P < 0.001). Adequate images were obtained in 96% of the attempts (55/57). The success rate at performing LP was 95% (54/57). Conclusions After a brief education intervention, pediatric emergency medicine physicians with little to no previous training in ultrasound can obtain adequate lumbar anatomic images and successfully perform LP in a simulated obese model. Comfort level with ultrasound significantly improves with a short course in ultrasound fundamentals.

Goal-directed Focused Ultrasound Milestones Revised: A Multiorganizational Consensus

In 2012 the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine released the emergency medicine milestones. The Patient Care 12 (PC12) subcompetency delineates staged and progressive accomplishment in emergency ultrasound. While valuable as an initial framework for ultrasound resident education, there are limitations to PC12. This consensus paper provides a revised description of criteria to define the subcompetency. A multiorganizational task force was formed between the American College of Emergency Physicians Ultrasound Section, the Council of Emergency Medicine Residency Directors, and the Academy of Emergency Ultrasound of the Society for Academic Emergency Medicine. Representatives from each organization created this consensus document and revision.

Right ventricular fractional area of change is predictive of ventilator support days in trauma and burn patients

Echocardiography has contributed to the care of critically ill patients but there remains a need for more publications about its association with outcomes to confirm its role. We conducted a retrospective review of trauma and burn patients that were admitted to our intensive care unit between 2015 and 2017 that underwent hemodynamic transesophageal echocardiography. Data collected included demographics, clinical and laboratory data. Right ventricle fractional area of change (RVFAC) measurements were performed on still mages obtained from mid-esophageal four-chamber-view clips. There were 74 patients, mean age was 51 years, and were predominantly white and male. Linear regression was used to test for the association between RVFAC and clinical outcomes. Adjusting for age, injury mechanism and injury severity, higher RVFAC was significantly associated with lower ventilator days (p = 0.03). Conclusion, higher right ventricle systolic function is associated with a lower number of ventilator support days in critically injured trauma and burn patients.

Elderly Female With Elbow Pain

[Ann Emerg Med. 2017;70:142.] A 66-year-old woman presented to the emergency department with 10 days of right elbow pain. She had recently been treated for an acute gout flare-up. Despite allopurinol therapy, the pain and swelling had worsened during the last 24 hours. The patient was afebrile on arrival, and right elbow examination result was notable for marked swelling and tenderness over the olecranon, with decreased range of motion because of pain. Needle aspiration of the olecranon bursa was performed.

Intraocular mass causing acute angle-closure glaucoma

Acute angle-closure glaucoma is a clinical phenomenon with potentially devastating consequences, including permanent blindness, if not promptly diagnosed and treated. We describe an unusual case of acute angle-closure glaucoma, leading to the detection of a uveal melanoma, a potentially life-threatening cause of glaucoma. Bedside ultrasonography of the eye was used to assist in the diagnosis, providing rapidly available diagnostic information about the size and extent of the tumor. Because acute angle-closure glaucoma may occur due to multiple etiologies, this case highlights the importance of uncovering occult causes of increased intraocular pressure. A 49-year-old man with no pertinent medical history presented to the hospital with sudden-onset, severe left eye pain that began 12 hours before arrival, followed by complete visual loss in the same eye 2 hours before arrival. The patient reported that the night before, he had been driving his truck when the pain suddenly occurred, and he stated that after 10 minutes, the pain was so severe that he was no longer able to drive. The patients visual loss was described as total loss of light perception in his left eye. He denied any pain or visual disturbances in the unaffected eye. Review of systems was pertinent only for headache and nausea since the day before, and no history of diabetes, hypertension, or coagulopathy. The patient stated he was taking no medications except Visine (tetrahydrozoline) for “blurry vision” over the last month, and he denied any previous episodes of left eye pain. Physical examination revealed an alert male in severe painful distress with normal vital signs and no evidence of trauma. His right pupil was 4 mm and reactive, whereas his left pupil was 6 mm and nonreactive with evidence of a yellowish mass posterior to the iris (Fig. 1). Gross inspection of the left eye revealed a mild perilimbic flush without conjunctival injection and a hazy cornea. Visual acuity in the right eye was within normal limits, and evaluation of the left eye revealed no light perception. Funduscopic examination was limited due to corneal haziness. Intraocular pressure in 0735-6757/

Foreign Body in the Tongue: A Novel Use for Emergency Department Ultrasonography

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