Man with headache and altered mental status

PresentationAn 83-year-old man presented for headache and altered mental status. Four days prior, he underwent endoscopic sinus surgery for nasal polyps. Over the two previous days, he gradually developed a headache and was brought to the emergency department when his wife noted mild confusion and generalised weakness. His examination was notable for a heart rate of 101 beats per minute, clear nasal discharge, meningismus and confusion to the date with generalised weakness. A lumbar puncture revealed cloudy cerebrospinal fluid (CSF) with a white blood cell count of 3519x10ˆ9/L (95% neutrophils). A CT scan of the head was obtained (figure 1).emermed;38/7/519/F1F1F1Figure 1Non-contrast CT scan of the head in axial plane. QUESTION: What is the appropriate next step in management?Obtain MRI of the brain to localise ischaemic damage.Administer broad-spectrum antibiotics, including pseudomonal coverage.Consult otolaryngology to arrange functional endoscopic sinus surgery for CSF leak closure.Consult neurosurgery for surgical decompression of mass lesion(s).

The Effect of Lights and Sirens on Critical Care Transport Time

BACKGROUND

In the prehospital setting, the use of ambulance lights and sirens (L&S) has been found to result in minor decreases in transport times, but has not been studied in interfacility transportation.

OBJECTIVE

The objective of this study was to evaluate the indications for L&S and the impact of L&S on transport times in interfacility critical care transport.

METHODS

We performed a retrospective analysis using administrative data from a large, urban critical care transportation organization. The indications for L&S were assessed and the transport times with and without L&S were compared using distance matching for common transport routes. Median times were compared for temporal subgroups.

RESULTS

L&S were used in 7.3% of transports and were most strongly associated with transport directly to the operating room (odds ratio 15.8; 95% confidence interval 6.32-39.50; p < 0.001). The timing of the transport was not associated with L&S use. For all transports, there was a significant decrease in the transport time using L&S, with a median of 8 min saved, corresponding to 19.5% of the overall transportation time without L&S (33 vs. 41 min; p < 0.001). The reduction in transport times was consistent across all temporal subgroups, with a greater time reduction during rush hour transports.

CONCLUSIONS

The use of L&S during interfacility critical care transport was associated with a statistically significant time reduction in this urban, single-system retrospective analysis. Although the use of L&S was not associated with rush-hour transports, the greatest time reduction was associated with L&S transport during these hours.

Anonymity Decreases the Punitive Nature of a Departmental Morbidity and Mortality Conference

OBJECTIVES

We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors.

METHODS

We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test.

RESULTS

Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous.

CONCLUSIONS

We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

OBJECTIVE

The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment.

METHODS

Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6-hour time periods during the first 48 hours of AC were collected and analyzed.

RESULTS

A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values.

CONCLUSIONS

The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.

Recurrent Hydrochlorothiazide-Induced Acute Respiratory Distress Syndrome Treated With Extracorporeal Membrane Oxygenation

BACKGROUND

Hydrochlorothiazide (HCTZ) is a commonly prescribed sulfonamide thiazide-type diuretic medication that has been associated with rare cases of noncardiogenic pulmonary edema.

CASE REPORT

A man in his 50s with a medical history notable for hypertension was transferred to our institution for evaluation of refractory hypoxemia. After taking an initial dose of HCTZ earlier in the day, he developed progressive respiratory failure and was intubated at a referring hospital. Progressive hypoxemia and acute respiratory distress syndrome (ARDS) developed and he was transferred to our institution for extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (vv-ECMO) was initiated in the Emergency Department and he was admitted to the intensive care unit. After several days of ECMO, his ARDS resolved and he was decannulated and extubated. Further history indicated that he had had two previous episodes of ARDS in the setting of HCTZ use without recognition of the inciting trigger, likely explaining his presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: One of the most commonly prescribed antihypertensives, HCTZ is associated with rare cases of pulmonary edema, which typically develop within minutes to hours of the initial dose of the medication. Although most cases resolve with supportive care, severe cases may require intubation and even vv-ECMO. The mechanism of the reaction is unknown, and affected individuals are typically able to tolerate other sulfonamide medications without issue.

Man with hand pain

CLINICAL INTRODUCTION: A right-hand dominant man was transferred to our institution for evaluation by the hand surgery service. He reported that the day prior he had been sliding a sheet of plywood across the ground when he lost his grip, causing the board to slide across his left hand. He presented to an outside hospital where local exploration of the wound did not reveal any foreign body. On arrival, he complained only of mild pain in his hand. Physical examination revealed erythema and swelling over the thenar eminence and a small open area without any drainage. Radiographs (figure 1) and ultrasonography (figures 2 and 3, online supplementary video 1 and 2) were performed.DC1SP110.1136/emermed-2018-207679.supp1Supplementary dataemermed;35/12/731/F1F1F1Figure 1Radiograph of the hand.emermed;35/12/731/F2F2F2Figure 2Long-axis ultrasonography of the hand.emermed;35/12/731/F3F3F3Figure 3Short-axis ultrasonography of the hand. QUESTION: What is you diagnosis?Fracture of the metacarpal of the thumb.Cellulitis of the thenar eminence.Abscess of the thenar eminence.Retained foreign body.

Epidemiology, Pathophysiology, Stratification, and Natural History of Pulmonary Embolism

Pulmonary embolism (PE) is a common and potentially fatal form of venous thromboembolism that can be challenging to diagnose and manage. PE occurs when there is obstruction of the pulmonary vasculature and is a common cause of morbidity and mortality in the United States. A combination of acquired and inherited factors may contribute to the development of this disease and should be considered, since they have implications for both susceptibility to PE and treatment. Patients with suspected PE should be evaluated efficiently to diagnose and administer therapy as soon as possible, but the presentation of PE is variable and nonspecific so diagnosis is challenging. PE can range from small, asymptomatic blood clots to large emboli that can occlude the pulmonary arteries causing sudden cardiovascular collapse and death. Thus, risk stratification is critical to both the prognosis and management of acute PE. In this review, we discuss the epidemiology, risk factors, pathophysiology, and natural history of PE and deep vein thrombosis.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students

PURPOSE

Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum.

METHOD

Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills.

RESULTS

A total of 405 of their patients' charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1-37.1) minutes. Abstracted data confirmed that the students had successfully recruited a "high-risk" patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low.

CONCLUSIONS

Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.