J Emerg Med
-
One-fifth of patients with severe facial trauma suffer ophthalmic injury. Currently, patients presenting with mid-face injury to the emergency department (ED) undergo visual examination and then further assessment by ophthalmologists and with computed tomography (CT) scanning. The utility of the initial visual examination in the ED, performed by nonophthalmologists, remains unclear. ⋯ We identified no significant difference between a comprehensive visual examination performed by nonophthalmologists in the ED, and improved ophthalmic outcomes. Physicians assessing patients with mid-face trauma in the ED should rule out eye emergencies, including retrobulbar hemorrhage and penetrating globe injury, and initiate expeditious CT scan and assessment by specialist ophthalmologists.
-
The emergency department (ED) is an ideal environment to teach learners about the "undifferentiated patient." Student learning may be inconsistent because of inherent variability in the ED. Previous research has suggested that standardizing the emergency medicine (EM) clerkship by implementing didactics and requiring students to see patients with particular chief complaints improves educational outcomes. ⋯ A DL model combining clinical and enhanced didactic requirements for an EM clerkship led to greater knowledge gain than the standard curriculum. This model may suggest ways to improve the educational experience in the EM clerkship.
-
Case Reports
Pylephlebitis Complicating Acute Appendicitis: Prompt Diagnosis With Contrast-Enhanced Computed Tomography.
Pylephlebitis, a rare complication of abdominal infections, is a septic thrombophlebitis of the portal venous system with high rates of morbidity and mortality. ⋯ We present a case of pylephlebitis complicating acute appendicitis and report the utility of a computed tomography scan in the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The prompt diagnosis and appropriate treatment of pylephlebitis are crucial to reduce morbidity and mortality, but clinical presentation is often nonspecific. A computed tomography scan is instrumental in the early diagnosis of pylephlebitis because it readily reveals the thrombus in the mesenteric or portal vein in the setting of acute appendicitis. Early and aggressive treatment with broad-spectrum antibiotics is necessary, and anticoagulation therapy can also be used to prevent bowel ischemia.
-
Left ventricular assist devices (LVADs) are a viable treatment option for patients with end-stage heart failure. LVADs can improve survival, quality of life, and functional status. The indications for LVAD placement to support left ventricular function are temporary support, a bridge to transplantation, or destination therapy. ⋯ A 61-year-old man with past medical history significant for advanced congestive heart failure from ischemic cardiomyopathy, status post LVAD (HeartMate II; Thoratec Corporation, Pleasanton, CA) placement 2009 as destination therapy, presented to the Emergency Department (ED) with implantable cardiac defibrillators firing four times that morning. While in the care of Emergency Medical Services, he was in ventricular tachycardia, and they gave him a bolus of amiodarone 150 mg intravenously prior to arrival in the ED. He was reportedly alert and oriented without any chest pain on arrival to the ED, where an electrocardiogram was obtained showing polymorphic ventricular tachycardia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must be familiar with the atypical presentations of potentially lethal dysrhythmias in this patient population. They must also be familiar with the major adverse events after LVAD implantation. These include device malfunction, cardiac dysrhythmias, bleeding, thromboembolism, neurological events, and infection. The causes of device malfunction can include thrombus formation with hemolysis, mechanical failure of the impeller, and driveline lead fractures with electric failure. Although time is critical in the heart failure patient with an LVAD failure or complication, expert consultation with cardiology or the LVAD specialist should occur when possible.
-
The use of point-of-care ultrasonography as a noninvasive diagnostic tool for soft tissue infections has been shown to be superior to clinical judgment alone in determining the presence or absence of an occult abscess. As ultrasound-guided procedures become standard of care, there is an increasing demand to develop better and inexpensive simulation models to educate trainees. To date, there are no low-cost models for abscess simulation that can be constructed with minimal preparation time, be reused, and withstand multiple procedural attempts. ⋯ A homemade high-fidelity simulation phantom that simulates an abscess in superficial soft tissue can be made inexpensively in <5 min and reused for numerous trainees. This model allows for training for procedures such as ultrasound-guided abscess drainage.