Sam S. Torbati

Frequency of spontaneous intracranial hypotension in the emergency department

Spontaneous intracranial hypotension is considered a rare disorder. We conducted a study on the frequency of spontaneous intracranial hypotension in the emergency department (ED). We identified patients with spontaneous intracranial hypotension evaluated in the ED of a large urban hospital between 1 January 2003 and 31 December 2006. For comparison, we also identified all patients with spontaneous subarachnoid haemorrhage (SAH). Eleven patients with previously undiagnosed spontaneous intracranial hypotension were evaluated in the ED during the four-year time period. All patients presented with positional headaches and the duration of symptoms varied from one day to three months. None of the patients were correctly diagnosed with spontaneous intracranial hypotension in the ED. During the same time period, 23 patients with aneurysmal SAH were evaluated. Spontaneous intracranial hypotension is more common than previously appreciated and the diagnosis in the ED remains problematic.

Acute Calcific Tendinitis of the Wrist

BACKGROUND Acute calcific tendinitis, a benign and self-limiting inflammatory condition commonly seen in the shoulder, is also described in many other tendons, including those in the hand and wrist. When involving the wrist, acute calcific tendinitis is often misdiagnosed and mistaken for infection. OBJECTIVE We present this case to increase familiarity with this condition to avoid errors in diagnosis resulting in inappropriate treatment with antibiotics or even surgery. CASE REPORT A 27-year-old man presented to the Emergency Department with a 2-week history of volar wrist pain, with sudden increase in pain associated with chills and new onset swelling and redness of the wrist. Plain radiographs showed characteristic soft-tissue calcification overlying the insertion of the flexor carpi ulnaris tendon into the wrist. Treatment with ibuprofen and splinting resulted in complete symptom resolution. CONCLUSION Acute calcific tendinitis is an important consideration in the differential diagnosis of acute wrist pain. Radiographs are helpful in confirming the diagnosis when symptoms and examination findings are characteristic.

Management of Factor Xa inhibitor-associated life-threatening major hemorrhage: A retrospective multi-center analysis

Background: Factor Xa (FXa) inhibitors, used for stroke prevention in atrial fibrillation and venous thromboembolism treatment and prevention, are the dominant non‐Vitamin K oral anticoagulants on the market. While major bleeding may be less common with these agents compared to warfarin, it is always a risk, and little has been published on the most serious bleeding scenarios. This study describes a cohort of patients with FXa inhibitor‐associated life‐threatening bleeding events, their clinical characteristics, interventions and outcomes. Methods: We performed a retrospective, 5‐center review of FXa inhibitor‐treated major bleeding patients. Investigators identified potential cases by cross‐referencing ICD‐9/10 codes for hemorrhage with medication lists. Investigators selected cases they deemed to require immediate reversal of coagulopathy, and reviewed charts for characteristics, reversal strategies and other interventions, and outcomes. Results: A total of 56 charts met the inclusion criteria for the retrospective cohort, including 29 (52%) gastrointestinal bleeds (GIB), 19 (34%) intracranial hemorrhages (ICH) and 8 (14%) others. Twenty‐four (43%) patients received various factor or plasma products, and the remainder received supportive care. Thirty‐day mortality was 21% (n = 12). Re‐anticoagulation within 30‐days occurred in 23 (41%) patients. Thromboembolic events (TEEs) occurred in 6 (11%) patients. No differences were observed in outcomes by treatment strategy. Conclusions: This cohort of FXa inhibitor‐associated major bleeding scenarios deemed appropriate for acute anticoagulant reversal illustrates the variable approaches in the absence of a specific reversal agent.

Decreased transport time to the surgical intensive care unit

INTRODUCTION Extended stay in the emergency department (ED) is associated with worse outcomes in critically ill trauma patients. We conducted a human factors analysis to better understand impediments for patient flow when a surgical ICU (SICU bed is available in order to reduce ED LOS. METHODS This is a retrospective review of all trauma patients admitted to a protected SICU through the ED during 2011 and 2014. In 2010, a 24-hour protected SICU bed protocol was implemented to make a bed readily available. During 2013 human factors analysis helped to describe flow disruptions; related interventions were introduced to facilitate rapid transport from the ED to SICU. The interventions required the following prior to CT scanning: immediate ICU bed orders placed by the ED physician and ED to ICU personnel communication. Direct transport from the CT scanner to the ICU was mandated. Data including patient demographics, injury severity, ED LOS, ICU LOS, and hospital LOS was collected and compared between 2011 (PRE) and 2014 (POST). RESULTS A total of 305 trauma patients admitted from the ED to the SICU were analyzed; 174 patients in 2011 (PRE) and 131 in 2014 (POST). Average age was 46 years and patients had a mean admission GCS and injury severity score (ISS) of 12.3 and 15.9, respectively. The cohorts were similar in age, mechanism of injury, initial vital signs, and injury severity. After implementing the human factors interventions, decreases were noted in the mean ED LOS (2.4 v. 3.0 hours, p=0.005) and ICU LOS (4.0 v. 4.8 days, p=0.023). No differences in hospital LOS or mortality were observed. CONCLUSIONS While an open SICU bed protocol may facilitate rapid transport of trauma patients from the ED to the ICU, additional human factors interventions emphasizing improved communication and coordination can further reduce time spent in the ED. LEVEL OF EVIDENCE Level IV, Economic/Decision.

Acute Kidney Injury in Elderly Trauma: Not Associated with Admission IVContrast

Background: Given the decline of kidney function with advanced age, we evaluated the association between admission CT with IV contrast and acute kidney injury (AKI) in trauma patients older than 70 years. Methods: A retrospective study was performed at an urban, academic Level I trauma center from January 1, 2006 to December 31, 2010. Trauma patients older than 70 years with available serum creatinine at admission and 48 to 72 hours post admission were included in the analysis. Patients who underwent an admission CT scan with IV contrast were compared to those who underwent admission CT without IV contrast. Mean creatinine levels and rate of AKI were compared. Stepwise logistic regression was performed to determine if IV contrast was an independent predictor of AKI. Results: A total of 453 elderly patients met inclusion criteria with a mean age of 82.2 years and overall mortality of 13%. Patients who received IV contrast were younger (80.7 vs. 83.1 years, p<0.01), although had similar demographics and baseline characteristics. The rate of AKI in patients who received IV contrast was similar to the rate of those who did not (21.1% vs. 22.6%, p=0.73). Additionally, IV contrast with admission CT was not an independent predictor of developing AKI (AOR 1.2; CI 0.72-1.98; p=0.50). Conclusion: Although a high ratio of elderly patients, approximately 1 in 5, was likely to develop AKI after trauma, this study demonstrates admission CT with IV contrast is not associated with AKI in trauma patients older than 70 years.

Orbital Compartment Syndrome Following Mechanical Fall

CASE PRESENTATION An 80-year-old woman with a history of hypertension presented to the emergency department (ED) with blunt facial trauma including a four-centimeter laceration of the right upper eyelid sustained during a ground-level mechanical fall. Upon arrival to the ED, she was confused, repetitive, and amnesic to events surrounding the fall. Computed tomography (CT) of the brain and orbits was rapidly obtained, and upon return from CT she reported new visual loss of the right eye with the ability to see only light. On exam, her globe was noted to be increasingly firm, full to palpation, and swollen shut. Physical examination also revealed new ophthalmoplegia, proptosis, subconjunctival hemorrhage, and afferent pupillary defect. Intraocular pressure (IOP) measured 50 mmHg in the right eye and 12 mm Hg in the left eye. CT demonstrated a hematoma within the right orbit impinging on orbital contents, confirming the diagnosis of orbital compartment syndrome (OCS). An emergent bedside lateral canthotomy and cantholysis (LCC) was performed by the emergency physician with reduction of her IOP and restoration of vision.

Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project

Objectives: Isolated acute vestibular syndrome (iAVS) presentations to the emergency department (ED) pose management challenges, given the concerns for posterior circulation strokes. False-negative brain imaging may erroneously reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS. Methods: We launched an institutional Quality Improvement initiative, using DMAIC methodology. The outcome measures [proportion of iAVS subjects who had HINTS-plus examinations and underwent neuroimaging by computed tomography/magnetic resonance imaging (CT/MRI)] were compared before and after the established intervention. The intervention consisted of formal training for neurologists and emergency physicians on how to perform, document, and interpret HINTS-plus and implementation of novel iAVS management algorithm. Neuroimaging was not recommended if HINTS-plus suggested peripheral vestibular etiology. If a central process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved only for thrombolytic time-window cases. Results: In the first 2 months postimplementation, HINTS-plus testing performance by neurologists increased from 0% to 80% (P=0.007), and by ED providers from 0% to 9.09% (P=0.367). Head CT scans were reduced from 18.5% to 6.25%. Brain MRI use was reduced from 51.8% to 31.2%. About 60% of the iAVS subjects were discharged from the ED; none were readmitted or had another ED presentation in the ensuing 30 days. Conclusions: Implementation of HINTS-plus evaluation in the ED is valuable and feasible for neurologists, but challenging for emergency physicians. Future studies should determine the “dose-response” curve of educational interventions.

Spontaneous Hemoperitoneum from Rupture of Massive Leiomyoma

CASE REPORT A 34-year-old woman presented to the emergency department (ED) with acute onset of severe abdominal pain and distention with associated diffuse tenderness and guarding. Her medical history was significant for a two-year history of fibroids, which contributed to mild menorrhagia. Within 30 minutes of arrival, the patient developed signs of shock with a blood pressure of 89/67 mmHg, heart rate of 115 beats per minute, and a drop in serial hemoglobin measurements from 8.4 g/dL to 6.8 g/dL. Point-of-care ultrasound showed a large amount of free fluid in the abdomen associated with a large abdominal mass originating in the pelvis. Emergent computed tomography (CT) imaging demonstrated a large amount of intra-peritoneal bleeding associated with massive fibroids as shown in Images 1-2. Exploratory laparotomy discovered 3L of hemoperitoneum as well as a roughly 30-week-sized uterus with multiple fibroids, two of which were torsed and actively bleeding. The patient received four units of packed red blood cells, underwent emergent supracervical hysterectomy without additional complications, and was eventually discharged on post-operative day 3. Surgical pathology demonstrated normal endocervical and endometrial tissue, as well as multiple intramural and subserosal leiomyomas measuring up to 17.8 cm in length.

ECONOMIC IMPACT OF FALSE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) CARDIAC CATHETERIZATION LABORATORY (CCL) ACTIVATIONS AT A MAJOR LOS ANGELES COUNTY STEMI-RECEIVING CENTER (SRC)

Cardiac catheterization laboratory (CCL) activation for ST-elevation myocardial infarction (STEMI) based on pre-hospital ECG has reduced door-to-balloon times, but CCL-cancellations remain a challenging problem and adversely effect staff morale. We examined the economic impact of CCL-cancellations

Renal Rupture Following Extracorporeal Shockwave Lithotripsy

A 41-year-old woman presented to the emergency department with a chief complaint of hematuria three days status post extracorporeal shockwave lithotripsy. The patient described a three-day history of worsening left-sided abdominal pain immediately following the procedure. She denied any fever, chills, changes in bowel habits, hematochezia, increased urinary frequency, urinary urgency, or dysuria. Physical exam revealed tenderness to palpation in the left upper quadrant, left flank and periumbilical region with mild guarding. Laboratory studies revealed an anemic patient with downward trending hematocrit (red blood cell count of 3.41 106/μL, hemoglobin of 10.6 g/dL, and a hematocrit of 31.3% down from 43% a week and a half prior). Urinalysis revealed red and cloudy urine with 3+ leukocytes. A chest radiograph was unremarkable. A computed tomography of the chest, abdomen, and pelvis showed a laceration to the lateral aspect of the mid left kidney with a hematoma measuring 3.2 cm in thickness (Figure). The patient was subsequently admitted to the hospital for monitoring and discharged on day nine.