J Emerg Med
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Case Reports
Polyarticular Septic Arthritis Secondary to Septic Thrombophlebitis of the Brachiocephalic Vein: A Rare Case Report.
Polyarticular septic arthritis (PASA) accounts for approximately 15% of all septic arthritides and is rare in immunocompetent adults. Even with appropriate therapy PASA's mortality rate is nearly 50%. ⋯ We report a rare presentation of PASA caused by idiopathic septic thrombophlebitis of the brachiocephalic vein in an immunocompetent adult female patient who presented with symptoms of right clavicular, left wrist, and right hip pain associated with fevers. Methicillin-sensitive Staphylococcus aureus was isolated in blood cultures and joint aspiration of one of the affected hips. Transesophageal echocardiogram was negative for valvular vegetations and computed tomography chest with contrast revealed thrombi in the brachiocephalic and subclavian veins extending to the superior vena cava. It also showed bilateral pulmonary nodules consistent with septic pulmonary emboli. No clear precipitant for the underlying septic thrombophlebitis was identified. Management was conservative, with systemic anticoagulation and IV antibiotics. The patient's symptoms improved, and she was discharged to subacute rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment of PASA in the emergency department is imperative to reducing overall morbidity and mortality associated with this condition. To the best of our knowledge, this is the only case report of idiopathic septic thrombophlebitis of the subclavian vein causing PASA in an immunocompetent adult.
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Point-of-care ultrasound is a fundamental tool in the emergency department when managing the critically ill patient. Determining a patient's hemodynamic status at the bedside can better guide resuscitation efforts. The left ventricular outflow tract velocity-time integral (VTI) is a validated, noninvasive, and rapidly acquired echocardiographic measurement that is analogous to stroke volume. ⋯ VTI is an objective tool for clinicians to assess the hemodynamic status of critically ill patients. Understanding the acquisition of VTI and proper application in the context of the patient's history, clinical examination, and other bedside ultrasound findings, should be reviewed within the emergency medicine residency ultrasound curriculum. This article provides a simple four-step protocol, as well as bedside applications and potential limitations for VTI in the ED.
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Data on extracorporeal cardiopulmonary resuscitation (ECPR) in patients with out-of-hospital cardiac arrest (OHCA) and initially nonshockable rhythms are limited. ⋯ Approximately 10% of initially nonshockable patients with OHCA, generally considered to be a poor prognosis, could acquire good neurological outcomes when they underwent ECPR with our indications.
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Drowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. ⋯ We present a case of 6-year-old boy was found by his friends submerged in sea water for 10-15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student. Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.
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In early 2020, New York City was the epicenter of the Coronavirus disease 2019 (COVID-19) pandemic in the United States. Older adults were at especially high risk. Telemedicine (TM) was used to shift care from overburdened emergency departments (EDs) to provide health care to a community in lockdown. TM options presented unique challenges to our diverse older adult population, including visual, hearing, cognitive, and language limitations. ⋯ TM use by older adults grew substantially at our institution during our initial COVID-19 surge. The same-day emergent referral rate and mortality rate reflect the high acuity represented in this cohort and points to the need for telehealth providers that are trained in triage and emergency medicine with a knowledge of local resource availability.