Joseph Minardi

Management of traumatic brain injury: first link in chain of survival

Traumatic brain injury is a significant cause of morbidity and mortality. The prehospital care of the patient with a traumatic brain injury is critical to maximizing the chances for a good outcome. Prehospital management of the traumatic brain injury patient is directed toward preventing and limiting secondary brain injury while facilitating rapid transport to an appropriate facility capable of providing definitive neurocritical care. Key points in management include the assessment of oxygenation, blood pressure, and mental status (as measured with the Glasgow Coma Scale) and the pupillary examination. Treatment strategies are directed toward maintaining adequate oxygenation and perfusion and treating herniation. Judicious use of temporary hyperventilation and hypertonic saline are considerations. This review provides the most recent evidence regarding the treatment of traumatic brain injury in the prehospital setting and introduces areas in need of future research.

Septic Hip Arthritis: Diagnosis and Arthrocentesis Using Bedside Ultrasound

BACKGROUND Septic arthritis of the hip is an infrequent disorder that is difficult to diagnose. Traditional methods of obtaining synovial fluid from the hip are not always available in most emergency departments. OBJECTIVE To report a case of atypical septic arthritis with the diagnosis and management significantly aided by the use of bedside ultrasound. CASE REPORT An 18-year-old pregnant woman presented with right hip pain, a normal temperature, and elevated inflammatory markers. She had no risk factors for septic arthritis. The differential diagnosis was broad, but the use of bedside ultrasound assisted in rapidly narrowing the differential, as well as guiding the diagnostic procedure. CONCLUSIONS Bedside ultrasound is a useful tool to evaluate inflammatory disorders of the hip and assists in hip arthrocentesis, a procedure that has not been traditionally performed by most emergency physicians.

Ruptured Splenic Artery Aneurysm: Rare Cause of Shock Diagnosed with Bedside Ultrasound

Splenic artery aneurysm rupture is rare and potentially fatal. It has largely been reported in pregnant patients and typically not diagnosed until laparotomy. This case reports a constellation of clinical and sonographic findings that may lead clinicians to rapidly diagnose ruptured splenic artery aneurysm at the bedside. We also propose a rapid, but systematic sonographic approach to patients with atraumatic hemoperitoneum causing shock. It is yet another demonstration of the utility of bedside ultrasound in critically ill patients, specifically with undifferentiated shock.

A study of rural upbringing and education on the intent of health professional students to work in rural settings

Objectives To explore whether student rural upbringing, rural training were associated with their intent to practice in a rural health care setting after graduation in the disciplines of Dentistry, Dental Hygiene, Medicine, Nursing, and Pharmacy at a large university Health Sciences Center in Appalachia. Methods Graduating healthcare professional students were surveyed to determine student rural background and training competency as compared to location of intended practice after graduation (N= 145). Differences were identified using descriptive statistics within and between healthcare disciplines using Spearman’s rank correlation and Kruskal-Wallis tests, Univariate, Chi-square and Pearson analyses for emergent themes or trends. Results Positive attitudes towards rural rotations and competency training were found. Twenty-one percent respondents graduated from high school in a rural setting (<2,500), while 4% reported their intent to practice in that setting. Conversely, 52% reported intent to practice in >50,000 population, while 12% grew up in this community size. Conclusions Student attitudes towards learning rural competency are positive; however, this survey suggests rural upbringing and training may not be sufficient to encourage health care professionals to practice in rural settings. More investigation is needed to determine effective incentives, perceived advantages or disadvantages and deterrents to rural healthcare practice.

Case 6: Abdominal Distention and Constipation in a 70-day-old Female Infant

1. Jeffrey Lancaster, MD* 2. Jessica Lear, MD* 3. Richard Brant, MD* 4. Brian Riedel, MD* 5. Joseph Minardi, MD† 1. *Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV 2. †Departments of Emergency Medicine and Medical Education, West Virginia University School of Medicine, Morgantown, WV A 70-day-old female infant presents to the emergency department (ED) with a 1-month history of abdominal distention and constipation. The patient was born at term via vaginal delivery. She is formula fed with a cow milk protein formula and routinely consumes 4 oz every 4 hours. She passed meconium within 24 hours after birth. However, since that time she has not stooled regularly, and her parents have administered daily diluted fruit juices and enemas every other day to promote defecation. Despite these interventions, her abdomen has become more distended, and the parents report that her constipation continues. In the ED her vital signs are temperature 98.6°F (37.0°C), blood pressure 111/62 mm Hg, pulse 137 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 100% on room air. Her examination shows a well-appearing baby in no apparent distress. Her cardiopulmonary examination findings are normal. Extremity examination shows capillary refill within 2 seconds, and there is no appreciable edema. Peripheral pulses are strong. The patient’s abdomen is distended but nontender and without any cutaneous findings suggesting portal hypertension. Bedside abdominal ultrasonography performed by the ED physician demonstrates ascites without any organomegaly (Fig 1). She is admitted to the pediatric service at that time. Figure 1. Ascites is seen in the pelvis surrounding multiple intestinal loops. Results of laboratory studies are largely normal (aspartate aminotransferase, alanine aminotransferase, albumin, electrolyte panel, and lipase) except for peripheral eosinophilia noted on the complete blood cell count (white blood cell count, 10,500/μL [10.5 × 109/L]; eosinophils, 15%; absolute eosinophil count, 1.5 × 109/L). The total serum immunoglobulin E (IgE) level is normal at …

Longitudinal Ultrasound Curriculum Incorporation at West Virginia University School of Medicine: A Description and Graduating Students' Perceptions: Longitudinal POCUS Curriculum at WVU

Sonography is a clinical tool being incorporated in multiple medical specialties with evidence of improved patient care and cost. Some schools have begun implementing ultrasound curricula. We hope to build upon that foundation and provide another potential framework of incorporation. There are several barriers, including curricular space, equipment and physical space, adequate faculty, and performing assessment.

Takotsubo Cardiomyopathy in the Emergency Department: A FOCUS Heart Breaker

Takotsubo cardiomyopathy (TCM) is an important condition for the emergency physician to consider in patients with cardiovascular symptoms. A 70-year-old woman presented with chest pain and nausea following emotional trauma. She had an elevated troponin and a normal electrocardiogram with no history of previous cardiac disease. Point-of-care focused cardiac ultrasound (FOCUS) showed reduced left ventricular systolic function with mid to apical hypokinesis. Cardiac catheterization revealed clean coronary arteries and confirmed the suspected diagnosis of TCM. Few reports emphasize the importance of FOCUS in the diagnosis and management of TCM in the emergency department. We detail FOCUS findings that assisted with diagnosis of TCM and describe how this quick, noninvasive imaging modality can be used to assess and manage emergent conditions.

Lipoleiomyoma Causing Adnexal Torsion A Rare Mass Initially Diagnosed on Bedside Screening Sonogram

Abdominal pain in women of reproductive age is a frequently encountered chief complaint in the emergency department. Adnexal torsion is a time-sensitive diagnosis that is essential for emergency physicians to consider in the initial differential diagnosis. Bedside sonography can be used to assist the clinician in the detection of adnexal masses placing the patient at risk for torsion. Lipoleiomyomas are uncommon, benign neoplasms consisting of variable portions of mature lipocytes, smooth muscle, or fibrous tissue. Very few cases have been reported, with no cases previously reported by emergency physicians using bedside ultrasound. A case is presented of a middle-aged woman who presented to the emergency department with acute lower abdominal pain. At the time of the initial history and physical examination, bedside screening sonogram was performed, which allowed rapid diagnosis of a large, heterogeneous, relatively avascular adnexal mass that was later identified as a lipoleiomyoma, a rare adnexal neoplasm, that resulted in adnexal torsion.

Occult Iliac Deep Vein Thrombosis in Second Trimester Pregnancy: Clues on Bedside Ultrasound

Isolated pelvic deep vein thromboses (DVT) are rare and difficult to diagnose, but they are more common in pregnant women and carry an increased risk of embolization. Pulmonary embolism is the most common non-obstetric cause of death in pregnancy. Compression ultrasound is the first-line imaging test for suspected lower extremity DVT, but it cannot usually aid in directly visualizing or easily diagnosing isolated pelvic DVT. Nonetheless, point-of-care ultrasound (POCUS) may provide valuable clues to help rule in pelvic DVT and expedite initiation of anticoagulant therapy. Such findings include increased venous diameter, increased resistance to compression, visible venous reflux, and blunted phasicity. This case presents an example of how these findings on POCUS led the emergency physician to make the difficult diagnosis of pelvic DVT at the bedside within seconds.

Testicular Rupture: A Tough Nut to Crack

Blunt scrotal injury represents a diagnostic dilemma for emergency physicians (EP). Consequently, point-of-care ultrasound (POCUS) has emerged as a tool for early investigation of the acute scrotum in the emergency department. We describe a case where an EP used scrotal POCUS to immediately visualize the loss of testicular contour and underlying heterogeneous parenchyma to rapidly make the diagnosis of testicular rupture in a young male presenting with scrotal trauma. The use of POCUS in this case expedited therapy, likely improving the patient’s outcome. To our knowledge, this is the first detailed description of testicular rupture diagnosed with POCUS by an EP