Nikhil Goyal

The utility of head computed tomography in the emergency department evaluation of syncope.

ObjectiveCurrent guidelines for evaluation of syncope recommend that in the absence of objective focal neurologic findings, head computed tomography (HCT) may not be necessary. Compliance with this recommendation is highly variable, which may be due in part to the lack of currently available evidence. We undertook the following investigation to determine whether HCT aids in the diagnostic investigation of syncope.MethodsThis study was a retrospective chart review of all adult patients who presented to an urban emergency department, and who had a HCT ordered for syncope, during a 6-month period in 2001. Patients with competing indications for HCT, or those with a presentation consistent with seizures were excluded. Charts were assigned to the “positive” or “negative” HCT group depending on whether the treating physician considered HCT findings relevant to the syncopal event.ResultsA total of 202 patients had a HCT performed for syncope. Eighty-five patients met one or more of the exclusion criteria. HCT of the remaining 117 patients were analyzed. None of the 117 patients had a HCT finding that was clinically related to the syncopal event.ConclusionsHCT yielded no relevant clinical findings in our entire sample of patients with syncope. Our findings combined with previous studies add to the growing body of evidence that HCT for syncope in the absence of focal neurologic findings may not be necessary.

USMLE Scores Predict Success in ABEM Initial Certification: A Multicenter Study

Introduction There are no existing data on whether performance on the United States Medical Licensing Examination (USMLE) predicts success in American Board of Emergency Medicine (ABEM) certification. The aim of this study was to determine the presence of any association between USMLE scores and first-time success on the ABEM qualifying and oral certification examinations. Methods We retrospectively collected USMLE Step 1, Step 2 Clinical Knowledge (CK) scores and pass/fail results from the first attempt at ABEM qualifying and oral examinations from residents graduating between 2009 and 2011 from nine EM programs. A composite score was defined as the sum of USMLE Step 1 and Step 2 CK scores. Results Sample was composed of 197 residents. Median Step 1, Step 2 CK and composite scores were 218 ([IQR] 207–232), 228 (IQR 217–239) and 444 (IQR 427–468). First-time pass rates were 95% for the qualifying examination and 93% for both parts of the examination. Step 2 CK and composite scores were better predictors of achieving ABEM initial certification compared to Step 1 score (area under the curve 0.800, 0.759 and 0.656). Step 1 score of 227, Step 2 CK score of 225 and composite score of 444 predicted a 95% chance of passing both boards. Conclusion Higher USMLE Step 1, Step 2 CK and composite scores are associated with better performance on ABEM examinations, with Step 2 CK being the strongest predictor. Cutoff scores for USMLE Step 1, Step 2 CK and composite score were established to predict first-time success on ABEM initial certification.

Left Ventricular Outflow Tract Pseudoaneurysm after Aortic Valve Replacement

Left ventricular outflow tract pseudoaneurysm is an uncommon complication following aortic valve replacement (AVR), occurring most frequently secondary to endocarditis. We present a case of a 47-year-old female with a history of intravenous drug abuse and a past surgical history of two AVRs (2001 and 2009 with aortic root replacement for endocarditis) who presented with symptoms of lower extremity weakness. Subsequent radiologic imaging revealed the presence of a left ventricular outflow tract pseudoaneurysm, which was surgically managed with a homologous conduit.

Prompt Diagnosis of an Unusual Cause of Obstructive Shock Using Point-of-Care Ultrasound.

BACKGROUND The patient presenting in an undifferentiated shock state can produce a diagnostic challenge for even the most seasoned clinician. CASE REPORT We present an unusual case of an elderly woman in obstructive shock from a large atrial mass that was promptly diagnosed with point-of-care ultrasound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound is a non-invasive tool that can help facilitate the early diagnosis of a patient in undifferentiated shock.

Pressor support during a Jarisch Herxheimer reaction after initiation of treatment for Weil's disease

We present a case of Weils disease complicated by a Jarisch-Herxheimer reaction (JHR) after initiation of antibiotics while in the emergency department requiring invasive monitoring and vasopressor support. The case is followed by a brief review of the JHR which is rarely observed with treatment of leptospirosis. A healthy 28-year-old female who recently returned from the Caribbean presented to the emergency department with flu-like symptoms. The patient appeared jaundiced with conjunctival suffusion and was ultimately treated with the appropriate antibiotics for leptospirosis in the ED. She decompensated subsequently, requiring supplemental oxygen, central and arterial line placement, and vasopressor support with norepinephrine. Although rarely encountered and not well reported throughout the literature, initiation of antibiotics can cause a JHR reaction given that Leptospira interrogans is a spirochete. This JHR may be self-limited and of short duration, or it can be prolonged and severe, requiring invasive therapies such as central line placement for vasopressor support and intubation. It is suggested that patients started on antibiotics for leptospirosis/Weils disease should be monitored in the emergency department for a short duration prior to discharge or transfer to a regular medical floor for observation given the possibility for decompensation.

Spontaneous Collapse of Bilateral Bullae with Conservative Management

We report a case of bilateral apical lung bullae that collapsed following an episode of community-acquired pneumonia with bilateral air fluid levels. With standard treatment for community-acquired pneumonia, management of a patient that may have qualified for bullectomy, (as in our case) showed complete resolution of all pathology without surgical intervention. Conservative management took precedence in alleviating pathology over surgical intervention.