Michael Falgiani

Communicating carotid-cavernous sinus fistula following minor head trauma

IntroductionA case of communicating carotid-cavernous sinus fistula (CCF) after minor closed head injury is presented.Case presentationA 45-year-old Caucasian male presented to the emergency department of a tertiary care hospital with the chief complaint of blurred vision and facial numbness. The patient had experienced a minor head injury 1 month ago with loss of consciousness. After a 2-week symptom-free period, he developed scalp and facial numbness, along with headache and vision problems. His vital signs were within normal limits, but on examination the patient was noted to have orbital and carotid bruits with several concerning neurological findings. CT and MRI confirmed the suspicion of carotid-cavernous sinus fistula, which was managed by cerebral angiography with coil embolization of this fistula. The patient was symptom free at the 8-month follow-up.DiscussionCarotid-cavernous sinus fistula is a rare condition that is usually caused by blunt or penetrating trauma to the head, but can develop spontaneously in about one fourth of patients with CCF. The connection between the carotid artery and cavernous sinus leads to increased pressure in the cavernous sinus and compression of its contents, and thereby produces the clinical symptoms and signs seen. Diagnosis depends on clinical examination and neuroimaging techniques. The aim of management is to reduce the pressure within the cavernous sinus, which results in gradual resolution of symptoms.

TBI surveillance using the common data elements for traumatic brain injury: a population study

BackgroundTo characterize the patterns of presentation of adults with head injury to the Emergency Department.MethodsThis is a cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of traumatic brain injury in adults. This IRB-approved project was conducted in collaboration with our Institution’s Center for Translational Science Institute. Data were entered in REDCap, a secure database. Statistical analyses were performed using JMP 10.0 pro for Windows.ResultsThe cohort consisted of 2,394 adults, with 40% being women and 79% Caucasian. The most common mechanism was fall (47%) followed by motor vehicle collision (MVC) (36%). Patients sustaining an MVC were significantly younger than those whose head injury was secondary to a fall (P < 0.0001). Ninety-one percent had CT imaging; hemorrhage was significantly more likely with worse severity as measured by the Glasgow Coma Score (chi-square, P < 0.0001). Forty-four percent were admitted to the hospital, with half requiring ICU admission. In-hospital death was observed in 5.4%, while neurosurgical intervention was required in 8%. For all outcomes, worse TBI severity per GCS was significantly associated with worse outcomes (logistic regression, P < 0.0001, adjusted for age).ConclusionThese cohort data highlight the burden of TBI in the Emergency Department and provide important demographic trends for further research.

“Bath Salts” Intoxication: A Case Report

We present a case of a potentially lethal ingestion of “Bath Salts.” After presentation, we briefly review the epidemiology and pathology of “bath salts” ingestion.

Visual Diagnosis: Pediatric Airway Emergency

We present a case of a potentially difficult airway emergency in a pediatric patient. After presentation, we briefly review critical differences between pediatric and adult airways and management of the airway during these emergencies.

Endocarditis-Induced Mycotic Brain Aneurysm following Right MCA Stroke

The diagnosis of cerebrovascular accident is extremely common in emergency medicine; however, CVA resulting from hemorrhage following mycotic brain aneurysm following embolic stroke is extremely uncommon. This case reports such an event.

Survey of Patient Knowledge and Expectations about a Free-Standing Emergency Department

Objectives. A free-standing emergency department (FSED) is defined as a facility that is structurally separate and distinct from a hospital and provides emergency care. Nationally, the number of FSEDs continues to grow, but the general public may have limited knowledge about the costs and services associated with FSEDs. The purpose of this paper is to survey patient knowledge and expectations about FSEDs. Methods. A convenience sample of patients presenting to a FSED was given a 19-item survey to complete. Results. 187 surveys were collected; 126 were included for analysis. 40% of respondents thought they could be seen by a specialist at the FSED, and 55% of patients did not know they had to be transferred for hospitalization if required. Most patients did not know that the cost of services at the FSED would be the same as that at the traditional ED. Convenience and perceived shorter wait times were the primary reasons patients selected the FSED for care. Conclusion. In general, patients do not have adequate knowledge about the costs and services associated with FSEDs. Education through marketing and advertising may be helpful in creating more public awareness about FSEDs.

Self-inflicted hyperkalemia: a case report

We present a case of a potentially lethal ingestion of potassium pills. After presentation, we briefly review the epidemiology and pathology of hyperkalemia.

An Analysis of Physician Productivity and Self-Sustaining Revenue Generation in a Free-Standing Emergency Department Medical Scribe Model

Objectives. A free-standing emergency department (FSED) is a facility that provides comprehensive emergency medical care similar to a traditional emergency department but is not attached to a hospital campus. Medical scribes are increasingly likely to work in free-standing emergency departments. The purpose of this study was to retrospectively investigate the benefits of a scribe program in an FSED. Methods. A retrospective, Institutional Review Board-approved analysis from December 1, 2013, to February 1, 2015, of free-standing emergency department medical data was extracted to determine if scribed charts resulted in increased revenue and improved throughput. Results. When scribes are present in the FSED there is a small, but statistically significant, decrease in time from patient arrival to provider by 2.74 minutes. Scribed charts collected

Jumping Sturgeon in the Suwannee River

4.69 more per chart and resulted in an increase in productivity. Incremental cost effectiveness ratios resulted in proven cost-utility with a net-positive effect. Conclusion. While there are some gains in terms of operational metrics and provider productivity with the addition of scribes to a free-standing emergency department, there is a net-positive financial impact of scribes. Implementing a scribe program at a FSED is cost-effective and justified from both an operational and a financial analysis.

Visual Diagnosis: Pearling: a case study

To the Editor: The following is presented to illustrate a unique outdoor injury that the wilderness provider may encounter. The Gulf Coast sturgeon (Acipenser oxyrinchus desotoi) is a large fish that can grow to weigh 200 to 300 pounds and up to 9 feet long. Gulf Coast sturgeons were listed as a threatened subspecies in 1991 in accordance with the Endangered Species Act of 1973. The Gulf Coast sturgeon population has been experiencing natural growth, and there have also been recent efforts to increase the population by a combined recovery and fishery management plan by the US Fish and Wildlife Service. The majority of these fish, generally found in Florida, are in the Suwannee River—biologists estimate 10,000 to 14,000. Sturgeons are an anadromous fish, which means that they live in salt water and come into freshwater rivers to breed. Sturgeons generally come into the Suwannee River in Florida around March and stay until October, when they return to the ocean. Unfortunately, this is a common time for recreational boaters to be using the river for fishing, swimming, or other leisure activities. In addition, sturgeons are known for their ability to jump out of the water, frequently jumping up to 6 feet in the air (Figure). There are many theories as to why the sturgeon jump, but no clear reason has been identified.