J Emerg Med
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Case Reports
Novel Uses of Point-of-Care Ultrasound for Pediatric Foreign Bodies: An Emergency Department Case Series.
Foreign bodies (FBs) are a diagnostic challenge to pediatric emergency providers. Point-of-care ultrasound (POCUS) is an important adjunct to the diagnostic pathway of children with suspected FBs. ⋯ This case series describes three examples of novel extended ultrasonography uses in the pediatric emergency department for the detection of FBs involving different organ systems (i.e., abdominal, esophageal, and scrotal). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: FBs are a diagnostic challenge to pediatric emergency providers. POCUS should be recognized as an important adjunct to the diagnostic pathway of children with suspected FBs. When used thoughtfully, it can narrow the differential diagnosis, guide further confirmatory investigations, reduce cognitive burden, and tailor downstream patient care.
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Anomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia. ⋯ We describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization.
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Compartment syndrome is a life-threatening complication of traumatic injury, most commonly, direct trauma. Back pain is a common cause of visits to the emergency department (ED) and often is treated without imaging or diagnostic testing. Lumbar paraspinal compartment syndrome is a rare cause of acute back pain. ⋯ A 43-year-old woman presented to the ED after direct trauma to the lower back. Laboratory studies revealed rhabdomyolysis and acute kidney injury, with examination findings and imaging consistent with lumbar paraspinal compartment syndrome. She was taken to the operating room for emergent fasciotomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is the job of the emergency physician to identify the red flags in history and physical examination that warrant further diagnostic testing. Early diagnosis and surgical consultation is the key in avoiding morbidity and achieving good outcomes in all forms of compartment syndrome.
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Emergency medicine residencies are commonly based out of large, urban medical centers with very little, if any, exposure to the practice of rural emergency medicine. With one-third of all hospitals and one-fifth of the entire United States population residing in rural areas, more can be done to prepare residents for a career in such a setting. Potential changes include increasing access to rotations at rural sites and altering didactic content and bedside teaching to take into consideration practice with limited access to specialists. In doing so, emergency medicine residents will be better trained and the residents of rural America will be better served.