J Emerg Med
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First rib fractures and traumatic Horner's syndrome are both quite rare, which can make it difficult to properly diagnose the combination of these 2 conditions in the emergency department. These conditions may be associated with severe medical emergencies, such as ongoing carotid dissection. ⋯ We present the case of a 33-year-old man who sustained fractures to his right second, third, and fourth ribs and a delay in the diagnosis of left Horner's syndrome after he was involved in a traffic accident. Left Horner's syndrome was caused by a left transverse fracture of the first rib. This fracture was not detected on chest radiographs and required a 3-dimensional reconstructed neck computed tomography scan for detection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In the diagnosis of carotid artery dissection, conventional angiography is the criterion standard but is considered invasive. CTA is less invasive, time-saving, and can show more anatomic structures in the neck in addition to the carotid arteries. It is a good screening diagnostic modality in the traumatology department. Although the treatments for Horner's syndrome and first rib fracture are conservative, the early diagnosis of both conditions can resolve the anxiety and uncertainty experienced by both doctors and patients.
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Observational Study
Emergency Department Crowding in Relation to In-hospital Adverse Medical Events: A Large Prospective Observational Cohort Study.
Emergency department (ED) crowding has been linked with adverse medical events. However, this association was inadequately controlled for potential confounding variables. ⋯ Failing to control for baseline risk factors may have led to false-positive associations between ED crowding and mortality in previous studies. After controlling for risk factors, we showed that ED crowding was associated with longer hospital stays but not with increased mortality.
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Brugada pattern (BrP) findings on electrocardiogram (ECG) are mandatory for the diagnosis of Brugada syndrome (BrS). BrS is an incompletely understood cause of sudden cardiac death. ⋯ Our patient was a young woman who was using topical nicotine for assistance in smoking cessation at a relatively high dose compared to her daily cigarette intake. She presented with symptoms of mild nicotine toxicity and had an ECG with a type 1 BrP. An ECG the next day was normal and electrophysiology consultation was conducted. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Recognition of a BrP ECG by emergency physicians is critical because this is the first step in diagnosing BrS, a condition that is characterized by ventricular dysrhythmias and sudden cardiac death. In addition, ECG abnormalities can be transient in nature, requiring vigilance by the emergency physician to prevent the patients' potential life threat from going undiagnosed. We present the first case to our knowledge of a BrP associated with nicotine toxicity. We also discuss treatment and disposition recommendations.
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In our academic emergency department, our senior residents lead their own patient care team, known as the red team (RT). Attending physicians are responsible for managing their own team (AT) and precepting the senior resident's cases. ⋯ We found that our patient care model did not lead to an increased number of M&M cases and RT cases were not associated with worse outcomes overall. Additionally, there was no increased rate of M&M cases in the beginning of the academic year.