Jonathan Glauser

A case of renal artery thrombosis with renal infarction

Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition. Emergency physicians and other physicians need to consider this diagnosis in unexplained flank pain, especially in patients with risk factors for this disease. In this case report, the authors review a case of renal infarction caused by renal artery thrombosis in a patient with risk factors for thrombosis but no previous history of thromboembolism. A review of scholarly articles was performed and the case is discussed in the context of the current knowledge of this condition. Common presenting symptoms, features of the history and risk factors will all be discussed herein. Diagnostic evaluation of flank pain in the setting of the suspicion of renal infarction will be discussed, including the modalities of high-resolution computed tomography, renal angiography, scintography and ultrasound. Acute management and prognosis will also be discussed.

Diabetic muscle infarction: a rare complication of advanced diabetes mellitus

Diabetic muscle infarction is a rare complication of diabetes mellitus first described in 1965. It typically arises in patients with long-standing diabetes mellitus who have complications of the disease, including nephropathy, retinopathy, and neuropathy. It typically presents with acute onset of thigh pain with an associated palpable tender mass. Recurrent episodes in the same or opposite limb are common. Laboratory evaluation does not generally show any consistent abnormality except for poor glucose control. Histologic features of diabetic muscle infarction consist of large areas of muscle necrosis and edema. Magnetic resonance imaging (MRI) findings in patients without clinical evidence of infection may be typical enough to make tissue biopsy unnecessary. In the appropriate clinical setting, MRI may obviate invasive testing and is the preferred imaging modality. Treatment is supportive with analgesics, rest, and immobilization.

Venous Thromboembolism Prophylaxis in Hospitalized Heart Failure Patients

BACKGROUND Venous thromboembolism (VTE) is a concerning problem for hospitalized heart failure (HF) patients. Current recommendations are that all hospitalized New York Heart Association Class III or IV HF patients should receive VTE prophylaxis. Our purpose was to describe the rate of use and the characteristics of patients receiving VTE prophylaxis in the Acute Decompensated Heart Failure National Registry (ADHERE). METHODS AND RESULTS HF hospitalization episodes in ADHERE were analyzed. Patients were excluded from analysis if they were receiving Coumadin or intravenous heparin, had elevated troponin levels, underwent cardiac catheterization or dialysis before or during hospitalization, or were initially admitted to the intensive care unit. VTE prophylaxis was defined as low-molecular-weight or subcutaneous unfractionated heparin administered at any time during hospitalization and intravenous vasoactive therapy was defined as any inotrope, inodilator, or vasodilator. Chi-square, analysis of variance, and Wilcoxon tests were used for univariate and multivariate analyses. Logistic regression was used to evaluate outcomes. A total of 155,073 entries were evaluated, with 71,376 eligible for VTE prophylaxis; 21,847 (31%) received VTE prophylaxis. VTE prophylaxis patients were more often African American (28% versus 21%) or admitted from the emergency department (84% versus 79%), compared with those who did not receive VTE prophylaxis (both P < .0001). Medical history and initial presentation characteristics were similar, except edema, which was more likely in VTE prophylaxis patients (71% versus 66%, P < .0001). Patients receiving VTE prophylaxis more often received an intravenous vasoactive agent (23% versus 18%), angiotensin-converting enzyme inhibitor (61% versus 54%), or beta-blocker (63% versus 58%) during their hospitalization and were more likely discharged on an angiotensin-converting enzyme inhibitor (53% versus 49%) or beta-blocker (57% versus 54%) than non-VTE prophylaxis patients, all P < .0001. VTE prophylaxis patients were more often admitted to the intensive care unit (4.8% versus 2.5%, P < .0001) and had longer median hospital stays (4.2 versus 3.8 days, P < .0001). Mortality was similar between cohorts (3.0% versus 2.9%, P = .69). CONCLUSIONS Despite recommendations that all hospitalized New York Heart Association III and IV CHF patients receive venous thromboembolic disease prophylaxis, less than one third of eligible patients receive this guideline recommended therapy.

Emergency department experience with nonoral contrast computed tomography in the evaluation of patients for appendicitis.

Study Objectives The American College of Radiology lists oral contrast as an institution-specific option in the evaluation of right lower quadrant pain. Previous literature indicates that an accurate assessment for appendicitis can be made by CT using IV contrast alone, with significant time savings from withholding oral contrast. Before 2010, the protocol for CT use in the evaluation of possible appendicitis or undifferentiated abdominal pain routinely included oral contrast. The purpose of this study was to determine the incidence of repeat CT scans with oral contrast for the purpose of arriving at a final disposition in patients undergoing evaluation for abdominal pain. This analysis was also to determine if the general surgery service was willing and able to make accurate clinical determinations to operate without the use of oral contrast. Methods Consecutive abdominal CTs for nontraumatic abdominal pain were evaluated retrospectively over a 7-month period from January through July 2010. CT scans performed for evaluation of trauma were eliminated, as were cases in patients with known previous appendectomy or in cases in which appendicitis was not a consideration. Follow-up was by chart review over the ensuing 30 days for complications or need for surgery, which was not detected after the initial CT scan. The study was conducted at a teaching hospital, level I trauma center with an annual ED census of 99,000 visits. Results A total of 311 CT scans met the study criteria. No cases of appendicitis were missed. Two patients were operated on based upon inflammatory findings in the right lower quadrant, one with typhlitis, the second with possible inflammatory bowel disease versus typhlitis. In each case, the diagnosis was made by CT, but the surgery service chose to operate based on clinical findings. Sixteen (5.14%; 95% CI, 3.2%–8.2%) cases of acute appendicitis were accurately identified. A normal appendix was visualized in 125 (40.2 %; 95% CI, 34.9–45.7) patients. No patients (0%; 95% CI, 0%–1.2%) required a repeat CT scan with oral contrast as part of the workup. On 30-day follow-up by chart review, no (0%; 95% CI, 0%–1.2%) significant surgical problems were identified, and no cases of missed appendicitis were identified. Conclusions Abdominal CT scan without the use of oral contrast is accurate to allow for appropriate decision making by emergency physicians and general surgeons. In our series, no patients required repeat scanning. Further assessment by larger studies is appropriate.

Cases from the Cleveland Clinic: cerebral venous sinus thrombosis presenting to the emergency department with worst headache of life

A 31 year old woman presented with the worst headache of her life and was diagnosed with cerebral venous sinus thrombosis (CVST) by routine unenhanced computed tomography (CT) scan, subsequently confirmed with magnetic resonance imaging (MRI) and magnetic resonance venography (MRV). Awareness of this less common cause for acute neurological presentation in the Emergency setting is important; the imaging characteristics of CVST are reviewed.

Airway Registry: A Performance Improvement Surveillance Project of Emergency Department Airway Management

The aim of this study was to determine if use of a standardized airway data collection sheet can survey airway management practices in an emergency department. Success rates and trends from the authors’ facility have been benchmarked against the National Emergency Airway Registry (NEAR). This study included all patients requiring invasive airway management during a 21-month period (July 1, 2005, through March 31, 2007). An audit form was developed and implemented to collect data on intubations. During the study period, 224 patients required invasive airway control. Of all airways managed by emergency medicine residents, the intubation success rate was 99% (200/203; 95% confidence interval [CI] = 96%-100%), with 3% of those (6/203; 95% CI = 1%-6%) requiring more than 3 attempts; 3 patients (1%; 95% CI = 0%-4%) could not be intubated and required a surgical airway. Use of an airway registry based on the NEAR registry as a benchmark of rates and types of successful intubation allows comparison of airway practices.

Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction

Ischemic heart disease is the leading cause of death in the world. More than half a million patients present to emergency departments across the United States each year with ST-segment elevation myocardial infarctions. Timely reperfusion is critical to saving myocardium at risk. Multiple studies have been conducted that demonstrate that improved care processes are linked to improved survival in patients having an acute myocardial infarction. This clinical policy from the American College of Emergency Physicians addresses key issues in reperfusion for patients with acute ST-segment elevation myocardial infarction. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: (1) In adult patients having an ST-segment elevation myocardial infarction, are there patients for whom treatment with fibrinolytic therapy decreases the incidence of major adverse cardiac events when percutaneous coronary intervention is delayed? (2) In adult patients having an ST-segment elevation myocardial infarction, does transfer to a percutaneous coronary intervention center decrease the incidence of major adverse cardiac events? (3) In adult patients undergoing reperfusion therapy, should opioids be avoided to prevent adverse outcomes? Evidence was graded and recommendations were made based on the strength of the available data.

A Multifaceted Quality Improvement Program Improves Endotracheal Tube Confirmation Documentation in the Emergency Department

Confirmation of endotracheal tube (ETT) position is an essential part of emergency department (ED) airway care. The study team evaluated the effect of a multifaceted quality improvement initiative on improving confirmation documentation rates. Rates of documentation of appropriate methods of ETT position confirmation were better for patients undergoing ETT placement in the study site ED than for those arriving already intubated (103/127 [81.1%] vs 19/71 [26.8%]; relative risk [RR] = 3.03; 95% confidence interval [CI] = 2.04 to 4.49). Overall rates of documentation of appropriate methods of ETT position confirmation were higher after the intervention (557/758 [73.5%] vs 122/198 [61.6%]; RR = 1.19; 95% CI = 1.06 to 1.34), with a greater increase among the group presenting to the ED with an ETT already placed (116/259 [44.8%] vs 19/71 [26.8%]; RR = 1.67; 95% CI = 1.11 to 2.51) compared with those intubated in the study site ED (103/127 [81.1%] vs 441/499 [88.4%]; RR = 0.92; 95% CI = 0.8389 to 1.0039).