Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department

BACKGROUND

Management of acute shoulder dislocation in the emergency department (ED) is common.

OBJECTIVE

This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED.

METHODS

The study was a retrospective case-control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts.

RESULTS

Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2-22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6-84.3%] vs. 68.0% [95% CI 56.8-77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6-97.3%] vs. 84.0% [95% CI 74.4-91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8-47.6%] vs. 29.3% [95% CI 19.9-40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4-31.0%] vs. 45.3% [95% CI 34.4-56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001).

CONCLUSIONS

The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.

Simultaneous Cardiocerebral Infarction Associated with Postcoital Activity

BACKGROUND

Cardiocerebral infarction (CCI) is a rare and life-threatening presentation of simultaneous acute myocardial infarction and acute ischemic stroke that requires prompt recognition and proper treatment. CCI is time sensitive and carries a high mortality rate. There is no standardized treatment algorithm that addresses both conditions simultaneously.

CASE REPORT

We present a 29-year-old man with simultaneous myocardial infarction and thrombotic stroke after coital activity. He presented to the Emergency Department with left-sided extremity weakness and numbness and radicular left-sided chest pain. He suffered a cardiac arrest during his evaluation and required emergent percutaneous coronary intervention with stent placement. He was resuscitated successfully and had an uncomplicated clinical course, with improved neurologic recovery prior to discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CCI is a rare condition that typically occurs in elderly patients with risk factors for cardiovascular disease. Management is challenging due to the time-sensitive nature of diagnosis and treatment of each condition. Treatment is not standardized, unlike individual evidence-based algorithms for thrombotic stroke and acute myocardial infarction. Risks and benefits for each treatment plan should be weighed and therapy should be directed toward the most immediate life-threatening process. This case would add to the literature surrounding this condition and help guide emergency physicians toward the most optimal treatment strategies for this patient population. This case also raises awareness of the existence of this condition and its potential presence in young, otherwise healthy patients.

Risk of contrast extravasation with vascular access in computed tomography

PURPOSE

Diagnostic computed tomography (CT) imaging, utilizing intravenous (IV) contrast administration, has become increasingly common. Potential IV contrast-associated complications include local skin and soft tissue reactions due to extravasation. The goal of this study is to describe the risk of contrast extravasation based on IV catheter anatomic location in patients receiving contrast-enhanced CT imaging.

METHODS

The study was conducted as a retrospective cohort study of patients receiving contrast-enhanced CT imaging performed over a 26-month period at a single institution. The rate of contrast extravasation was calculated by IV catheter vessel anatomic location and compared by relative risk (RR) and absolute risk reduction (ARR).

RESULTS

Of 17,767 contrast administrations for CT imaging studies performed, 14,558 met study inclusion criteria. Forty-nine (0.34%) extravasation events were identified. Forty-one (0.28%, 95% CI 0.21-0.39%) extravasation events were observed in 14,275 peripheral IV catheters placed in a non-upper arm location. Eight (2.8%, 95% CI 1.3-5.3%) extravasation events were observed in 283 IV catheters placed, most commonly with point-of-care ultrasound (POCUS) guidance, in upper arm vessels (RR 10.1, 95% CI 4.69-21.8). Non-upper arm located IV catheters were associated with an ARR of 2.54% (95% CI 0.61-4.47%) when compared to upper arm catheters.

CONCLUSIONS

IV catheter placement in upper arm vessels is associated with a relatively minimal increase in extravasation risk when compared to catheters placed in a non-upper arm location. In patients without alternative available peripheral vascular access, POCUS-guided upper arm IV cannulation may be an appropriate approach.

Evaluation of a novel curriculum on point-of-care ultrasound competency and confidence

INTRODUCTION

Point-of-care ultrasound (POCUS) education is a requirement of graduate medical education in EM. Milestones have been established to assess resident US competency. However, the delivery of POCUS education has not been standardized. This study aims to evaluate the impact of implementing a longitudinal, structured POCUS curriculum during EM residency on trainee competency and confidence.

METHODS

A prospective study of PGY-3 trainees before and after implementation of a novel POCUS curriculum was performed over an 18-month period at an EM residency training program. Curriculum design included longitudinal POCUS application-based monthly electronic content, bi-monthly residency conference sessions, and hands-on rotations. PGY-3 resident's POCUS knowledge was assessed with a 38-question multiple-choice and image-based exam. Further, PGY-3 residents were surveyed regarding POCUS confidence. Survey results evaluated provider confidence, satisfaction with the novel curriculum, and overall perception of POCUS utility scored on a 1 (low) to 5 (high) scale. Results were evaluated using an unpaired t test for data analysis.

RESULTS

Mean quiz scores of 8 pre-curriculum PGY-3 residents (84%; 95%CI 78.46-89.54) were not significantly different when compared with 13 post-curriculum PGY-3 residents (82%; 95%CI 77.11-86.89) (p = 0.6126). Survey results for pre-curriculum trainees across each section were 4.13 (95%CI 3.91-4.35), 3.68 (95%CI 3.32-4.04), and 4.33 (95%CI 4.06-4.6). Results for post-curriculum trainees trended higher for each section at 4.22 (95%CI 4.04-4.40) (p = 0.4738), 3.84 (95%CI 3.52-4.16) (p = 0.5279), and 4.49 (95%CI 4.21-4.77) (p = 0.4534).

CONCLUSIONS

Implementation of a structured, longitudinal POCUS curriculum resulted in a trend towards improved trainee confidence, satisfaction, and perception of POCUS. Future studies are needed to identify the optimal structure for POCUS educational content delivery and competency assessment for EM resident providers.

Evaluation and Management of the Emergency Department Headache

The acute headache in the emergency department (ED) poses a diagnostic dilemma that may overwhelm providers attempting to weigh the cost of advanced workups against the risk of missing serious pathology. While the majority of headache concerns are benign primary headache disorders, identifying life-threatening secondary causes of headache-which may be broadly categorized into structural, infectious, and vascular causes-is the primary focus of evaluation in the ED. Secondary headaches are associated with a high morbidity and mortality, and require strict scrutiny of the history and physical examination to adequately risk-stratify patients. Innovative and emerging technologies may further assist providers in the diagnosis of headache, and challenge previous gold-standard diagnostic evaluations. Herein, we present a general overview of the workup and management of headaches in the ED, with a special section for diagnostic considerations in evaluating for acute meningitis, subarachnoid hemorrhage, and acute angle-closure glaucoma.

Implications of language barrier on the diagnostic yield of computed tomography in pulmonary embolism

OBJECTIVES

To determine if a physician-patient language barrier impacts the diagnostic accuracy of pulmonary embolism (PE) evaluation.

METHODS

A retrospective chart review, conducted between June 2015 and December 2016, of a consecutive sample of diagnostic computed tomography pulmonary angiogram (CTPA) studies performed on adult patients. Positive and negative CTPA scans were further categorized by patient language and the positive diagnostic yield was determined for each language group. A post collection sub-analysis was performed to determine the yield when interpreter services were identified as necessary.

RESULTS

The yield for English speaking patients was 10.24% (92/898, 95% CI 8.39% to 12.36%), similar to the yield in Spanish speaking patients of 9.40% (25/266, 95% CI 6.31% to 13.37%, P=0.69). This contrasted with the yield in patients who identified as bilingual, which was significantly lower at 1.41% (1/71, 95% CI 0.07% to 6.75%) compared to both English-(P<0.02) and Spanish-only speakers (P<0.03). The yield for non-English speaking patients who requested an interpreter was 7.37% (14/190, 95% CI 4.26% to 11.77%) versus 3.23% (2/62, 95% CI 0.54% to 10.25%, P=0.25) in those who did not.

CONCLUSIONS

The diagnostic yield in English- and Spanish-only speaking patients was similar, however, the yield in those that self-identified as bilingual was significantly lower. In patient groups in which a language barrier existed and an interpreter was not utilized, there was a trend toward a lower diagnostic yield. This suggests an increased propensity to order diagnostic imaging when potential communication barriers exist.

Postcesarean endometritis: a brief review and comparison of three antibiotic regimens

Three different antibiotic regimens (trospectomycin plus azteonam, clindamycin plus azteonam, and triple antibiotics-ampicillin plus clindamycin plus gentamicin) were all effective in treating patients with postcesarean endometritis. Patients are frequently cured clinically despite the fact that the offending organisms may be isolated in post-treatment cultures. Treatment of postcesarean endometritis without obtaining endometrial cultures is acceptable gynecologic practice. Obtaining post-treatment cultures is clearly not cost effective nor clinically beneficial. Drug treatment efficacy should be evaluated by clinical response. This communication is the first to report the new antibiotic, trospectomycin, in the treatment of postcesarean endometritis. Further clinical trials are currently underway.