Kenneth H. Butler

Elder Abuse and Neglect Definitions, Epidemiology, and Approaches to Emergency Department Screening

Elder abuse and neglect is estimated to affect approximately 700,000 to 1.2 million elderly people a year with an estimated annual cost of tens of billions of dollars. Despite the large population at risk, its significant morbidity and mortality, and substantial cost to society, elder abuse continues to be underrecognized and underreported. This article aims to increase the awareness of elder abuse by reviewing the demographics, epidemiology, and risk factors of elder abuse, followed by a discussion of screening tools and ways to increase awareness and reporting.

Management of the difficult airway: alternative airway techniques and adjuncts

Rapid-sequence intubation using conventional laryngoscopic technique remains the standard of airway management in emergency medicine and continues to have a success rate of approximately 98%. Preparation and proper intubation technique must be optimized at the initial attempt using direct laryngoscopy. Failure causes multiple repeated attempts, leading to a failed airway. Each repeated attempt increases the likelihood of bleeding, oral, pharyngeal, and laryngeal edema, and malposition, causing decreased visualization of the glottic opening, equipment failure, and hypoxia. Preparation must be an ongoing process. Faulty suction, no oxygen source, choice of the wrong laryngoscopic blade or ETT, poor light source, or misplaced equipment can domino into mechanical failure. Intubation equipment stations must be inventoried constantly, organized, and kept simple in their layout to decrease confusion during selection. Medication for sedation and paralysis should be readily available and not kept distant from the intubation station in a medication-dispensing unit that would require time for acquisition. Proper positioning of the patient remains paramount for alignment of the oral, pharyngeal, and laryngeal axis to provide optimal visualization of the vocal cords. Proper technique during insertion of the laryngoscope blade in the oral cavity for displacement of the tongue must be ensured. Without proper technique, even with proper positioning, the glottic opening cannot be visualized. Laryngeal pressure to maneuver the larynx into position should be exerted initially by the laryngoscopists right hand and, when in view, maintained by an assistant to free the laryngoscopists hand for ETT insertion. With preparation and proper technique, the first attempt is the best attempt, and the vicious cycle of multiple attempts and complications will be averted.

Vertebral Artery Dissection Presenting as Acute Cerebrovascular Accident

Vertebral artery dissection is a lesser known but significant cause of stroke in young, healthy people. Given its infrequency of presentation, emergency physicians may not always recognize its common symptoms--vertigo, diplopia, ataxia, and dysarthria--as a stroke. In this case report, we describe a patient with vertebral artery dissection presenting with atypical symptoms and discuss the epidemiology, risk factors, presentation, clinical examination findings, imaging modalities, and treatment of this disease.

Not Just Another “Found Down”: Concomitant Upper Arm and Gluteal Compartment Syndrome

BACKGROUND Compartment syndrome is often considered in patients with long-bone fractures and soft-tissue injuries, but is not as commonly associated with a period of unconsciousness. CASE REPORT A 65-year-old man was brought to our emergency department (ED) because he had lost consciousness for an unknown amount of time after snorting heroin. He had severe pain in his upper right arm. Physical examination revealed right arm edema, paresthesia, tenderness, and firmness to palpation. During the ED assessment, the patient began to experience pain in his right hip to a degree exceeding examination findings. We considered compartment syndrome affecting his upper arm as well as his gluteal muscles. The patient was taken to the operating room for fasciotomy. The triceps muscle was found to be bulging out of the compartment, demonstrating advanced compartment syndrome. A posterior approach to the hip allowed the gluteal sling and the fascia to be released, eliminating tension on the gluteus medius/minimus and gluteus maximus compartments. With physical therapy, the patient regained full flexion and extension in his arm at the elbow, partial extension of his wrist, and range of motion and strength in his hip. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: If not recognized, compartment syndrome can jeopardize limb and life. It should be considered in patients experiencing inordinate pain, especially if they were found unconscious at the incident scene. Pressure-induced ischemia can impair muscle function within hours. If it is not relieved with fasciotomy, the patient can sustain irreversible functional loss.