Journal of Emergency Medicine最新文献

{"title":"Stethoscopes no longer need to touch patients","authors":"W. Frank Peacock MD, FACEP, FACC, FESC","doi":"10.1016/j.jemermed.2024.03.025","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.03.025","url":null,"abstract":"<div><h3>Background</h3><p>It is clear that, while stethoscopes are commonly used in cancer patients, they are frequently contaminated with pathogens. Even 60 seconds of alcohol swab cleaning doesn't reliably provide sterile contact. Thus ultimately, stethoscopes are potential vectors that transmit pathogens when touching patients. A proposed draft of the new 2024 CDC guidelines mandates that if shared patient-care items are used (e.g., stethoscopes), they must be cleaned and disinfected between patients. This requires that the stethoscope must be cleaned and disinfected between every single patient contact, or a disposable option used. Unfortunately, studies demonstrate that disposable stethoscopes are inferior auscultation tools, vs. the personal stethoscope. Therefore, to be in compliance with 2024 CDC guidelines improvements in personal stethoscope hygiene are required. The DiskCover is a touch free applied single use disposable stethoscope barrier consistent with CDC guidelines. We performed an in vitro investigation the efficacy of the DiskCover (Asepticscope, Inc, San Diego, CA) in providing an aseptic patient auscultation.</p></div><div><h3>Methods</h3><p>This was a prospective, randomized evaluation of the ability of the DiskCover to prevent patient exposure to pathogens found on the stethoscope. Stethoscope diaphragms were inoculated with Candida Albicans (C. Albicans), Clostridioides Difficile (C. Diff), Extended- Spectrum B-Lactamase Producing Escherichia Coli (ESBL), Methicillin Resistant Staphylococcus Aureus (MRSA), Pseudomonas Aeruginosa (P. Aeruginosa), and Vancomycin- Resistant Enterococcus Faecium (VRE), then randomized to either DiskCover placement or control (no DiskCover). Stethoscope's then underwent aerobic or anerobic incubation.</p><p>Diaphragm cultures were obtained at 0.25, 0.5, 2, 4, and 24 hours of incubation, and placed on Blood, Chocolate, and MacConkey agar. Colony formation was subsequently manually counted.</p></div><div><h3>Results</h3><p>Stethoscope diaphragms with a DiskCover were sterile in 100% of cases, while those without Discover's had extensive pathogen contamination. Compared to all controls, for all species of pathogens, all DiskCover contacts were sterile (p&lt;0.05 for all comparisons).</p></div><div><h3>Conclusions</h3><p>DiskCovers provided a sterile point of contact in all instances vs. control, which had large numbers of pathogenetic colonies.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"66 6","pages":"Pages e740-e741"},"PeriodicalIF":1.5,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141243277","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Painless Aortic Dissection Associated with Tyrosine Kinase Inhibitor Therapy","authors":"Huda Fatima MD,&nbsp;Kalen Jacobson MD","doi":"10.1016/j.jemermed.2024.03.029","DOIUrl":"https://doi.org/10.1016/j.jemermed.2024.03.029","url":null,"abstract":"<div><h3>History of presentation</h3><p>A 69-year-old male presented to the ED with a thoraco-abdominal aortic dissection (AD) (DeBakey type IIIB/Stanford classification B) and an intramural thoracic wall hematoma, detected during CT imaging. He arrived with hypertension (BP 160/92, heart rate 81) but was asymptomatic. Physical examination revealed palpable pulses.</p></div><div><h3>Past medical history</h3><p>Stage IV anorectal mucosal melanoma treated with ipilimumab/nivolumab, nivolumab+axitinib, radiation, currently on nivolumab+relatlimab. Prior superior mesenteric and right external artery dissection, right common iliac artery aneurysm, central adrenal insufficiency, hypothyroidism and recent hypertension-related syncopal episodes, leading to discontinuation of Losartan.</p></div><div><h3>Investigations</h3><p>Lab work was normal, EKG showed normal sinus rhythm. Echocardiogram was normal with ejection fraction 60-65%.</p></div><div><h3>Management</h3><p>The patient received IV labetalol and esmolol, following which BP improved. CT indicated chronicity with proximal thrombosis, and surgical intervention was not recommended. Cardiology started coreg 3.125 mg twice daily and a low-dose statin. He was discharged with oral anti-hypertensive meds for outpatient follow-up.</p></div><div><h3>Causes</h3><p>Hypertension, aging, atherosclerosis, connective tissue diseases like Marfan and Ehlers-Danlos syndromes, hereditary factors like Turner syndrome and bicuspid aortic valve, coarctation of the aorta, previous cardiac surgery, smoking, cocaine use, and iatrogenic factors such as VEGFR and TK inhibitors.</p></div><div><h3>Mechanism of action</h3><p>AD results from arterial wall tearing, causing a false lumen due to blood leakage through aortic media [2]. Stress or degeneration factors contribute [2]. Axatinib, a tyrosine kinase inhibitor blocking the TK activities of VEGFR, can lead to hypertension and cardiac dysfunction linked to AD [3]. It's unclear if AD-related hypertension is due to axatinib, suggesting tyrosine kinase inhibitors may directly contribute to AD.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"66 6","pages":"Pages e742-e743"},"PeriodicalIF":1.5,"publicationDate":"2024-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141243280","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Congenital Long QT Syndrome Unmasked by Albuterol in an Adolescent with Asthma","authors":"Jad Zreik BS ,&nbsp;Martin J. LaPage MD ,&nbsp;Hani Zreik MD","doi":"10.1016/j.jemermed.2024.05.011","DOIUrl":"10.1016/j.jemermed.2024.05.011","url":null,"abstract":"<div><h3>Background</h3><p>Patients with congenital long QT syndrome (LQTS) are prone to ventricular dysrhythmia but may be initially asymptomatic with a normal QTc interval on resting electrocardiogram (ECG). Albuterol is listed as a medication that poses a “special risk” to patients with congenital LQTS, but its effects have been rarely described. We present a case of previously unknown, asymptomatic congenital LQTS unmasked by albuterol in an adolescent with asthma.</p></div><div><h3>Case Report</h3><p>A 12-year-old girl with a history of asthma presented to the emergency department (ED) with shortness of breath, wheezing, and tachycardia for 24 h, consistent with acute asthma exacerbation. She received two doses of her home albuterol inhaler 2 h prior to presentation. Initial ECG demonstrated a QTc of 619 ms. Her remaining history, clinical examination, and laboratory workup, including electrolytes, were unremarkable. She was observed with cardiac monitoring before being discharged from the ED in stable condition for next-day outpatient pediatric cardiology follow-up. Resting office ECGs revealed QTcs from 440–470 ms. Exercise stress test revealed QTc prolongation of 520 ms and 500 ms at minute-2 and minute-4 of recovery, respectively. Genetic testing revealed heterozygous pathogenic variants in KCNQ1, consistent with type 1 LQTS.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>Albuterol may be a cause of marked QTc prolongation in ED patients with underlying congenital LQTS, which can be a diagnostic clue in previously unidentified patients. Extreme QTc prolongation also serves as an indication in the ED for Cardiology consultation, laboratory evaluation for electrolyte imbalances, and observation with cardiac monitoring.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 5","pages":"Pages e446-e450"},"PeriodicalIF":1.2,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142140271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An Uncommon Cause of Testicular Infarct: A Case Report and Review of the Literature of Testicular Infarcts From Laparoscopic Inguinal Hernia Repair","authors":"Jared Wenn DO,&nbsp;Brian Patrick Murray DO,&nbsp;Ross W. Kynast MD,&nbsp;Jessica Zhen MD","doi":"10.1016/j.jemermed.2024.05.006","DOIUrl":"10.1016/j.jemermed.2024.05.006","url":null,"abstract":"<div><h3>Background</h3><p>Testicular ischemia requires timely diagnosis and definitive management to avoid serious consequences such as orchiectomy. It is almost always caused by testicular torsion; however, there are other causes to be aware of.</p></div><div><h3>Case Report</h3><p>A 32-year-old man developed testicular ischemia following a laparoscopic robotic-assisted inguinal hernia repair with preperitoneal mesh. The ischemia progressed to a fully infarcted testicle with no evidence of torsion on subsequent surgical exploration. He ultimately did require an orchiectomy.</p></div><div><h3>Why should an Emergency Physician be aware of this?</h3><p>While extremely rare, testicular ischemia or infarct must be considered in patients presenting with testicular pain shortly after inguinal hernia repair. Emergent surgical evaluation and loosening of the hernia mesh may be required to salvage the testicle.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 4","pages":"Pages e375-e378"},"PeriodicalIF":1.2,"publicationDate":"2024-05-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142055802","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Postures","authors":"Evelyn M. Potochny DO","doi":"10.1016/j.jemermed.2024.05.008","DOIUrl":"10.1016/j.jemermed.2024.05.008","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 5","pages":"Page e486"},"PeriodicalIF":1.2,"publicationDate":"2024-05-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142145773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Role of Troponin Testing in Patients with Supraventricular Tachycardia, Systematic Review and Meta-Analysis","authors":"","doi":"10.1016/j.jemermed.2024.05.010","DOIUrl":"10.1016/j.jemermed.2024.05.010","url":null,"abstract":"<div><h3>Background</h3><p>Supraventricular tachycardia (SVT) is commonly evaluated in the emergency department (ED). While troponin has been shown to be elevated in SVT, its usefulness for predicting coronary artery disease and future adverse cardiovascular outcomes has not been shown.</p></div><div><h3>Objectives</h3><p>We aimed to evaluate the prognostic utility of troponin measurement as part of SVT management in the ED.</p></div><div><h3>Methods</h3><p>We performed a literature search in the PubMed and Scopus databases from inception to August 30, 2023, including all studies reporting troponin measurements in adult patients (age &gt; 18 years) presenting to the ED with supraventricular tachycardia. The primary outcome of interest for this study was the prevalence of elevated troponin in patients with SVT. Secondary outcomes included the prevalence of major adverse cardiac events (MACE) and additional cardiac testing with significant findings.</p></div><div><h3>Results</h3><p>We included 7 studies (500 patients) in our analysis. Six studies reported the number of patients with SVT and elevated troponin, with a pooled prevalence of 46% (95% CI 27–66%, I² 93%). The pooled prevalence of all MACE in our study was 6% (95% CI 1–25%), while the prevalence for MACE among patients with elevated serum troponin levels was 11% (95% CI 4–27%).</p></div><div><h3>Conclusions</h3><p>Troponin levels are frequently ordered for ED patients with SVT and are often elevated. However, this review suggests that they have low prognostic value in predicting MACE.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 5","pages":"Pages e402-e413"},"PeriodicalIF":1.2,"publicationDate":"2024-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141137405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Can I Discharge This Adult Patient with Abnormal Vital Signs From the Emergency Department?","authors":"","doi":"10.1016/j.jemermed.2024.05.009","DOIUrl":"10.1016/j.jemermed.2024.05.009","url":null,"abstract":"<div><h3>Background</h3><p>Vital signs are an essential component of the emergency department (ED) assessment. Vital sign abnormalities are associated with adverse events in the ED setting and may indicate a risk of poor outcomes after ED discharge.</p></div><div><h3>Clinical question</h3><p>What is the risk of adverse events among adult patients with abnormal vital signs at the time of ED discharge?</p></div><div><h3>Evidence review</h3><p>Studies retrieved included 6 retrospective studies with adult patients discharged from the ED. These studies evaluated adverse outcomes in adult patients discharged from the ED with abnormal vital signs. Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians.</p></div><div><h3>Conclusion</h3><p>Based on the available evidence, the specific vital sign abnormality and the number of total abnormalities influence the risk of adverse outcomes after discharge. Vital sign abnormalities at the time of discharge also increase the risk of ED revisit. The most common abnormal vital sign at the time of discharge is tachycardia.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 5","pages":"Pages e487-e493"},"PeriodicalIF":1.2,"publicationDate":"2024-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141131978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Perplexing Purple Rash","authors":"","doi":"10.1016/j.jemermed.2024.04.013","DOIUrl":"10.1016/j.jemermed.2024.04.013","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 3","pages":"Pages e315-e317"},"PeriodicalIF":1.2,"publicationDate":"2024-05-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141141807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Rare Case of an Adult with Spinal Cord Injury Without Neuroimaging Abnormality (SCIWONA)","authors":"","doi":"10.1016/j.jemermed.2024.04.008","DOIUrl":"10.1016/j.jemermed.2024.04.008","url":null,"abstract":"<div><h3>Background</h3><p>Spinal cord injury without radiographic abnormality (SCIWORA) is defined as having clinical symptoms of traumatic myelopathy with no radiographic or computed tomographic features of spinal fracture or instability. An abnormal finding, such as a fracture, subluxation, or abnormal intersegmental motion at the level of the spinal cord injury, excludes SCIWORA as the diagnosis. Prevalence of SCIWORA is highest among children younger than 8 years, and is a diagnosis seen primarily in children, owing to anatomic differences that put children at more risk of this condition. In more recent years, with the increasing use of magnetic resonance imaging in patients with suspected spinal cord injury, a new term, <em>spinal cord injury without neuroimaging abnormality</em> (SCIWONA) has been suggested as a more specific way to describe cases of SCIWORA that have negative neuroimaging.</p></div><div><h3>Case Report</h3><p>Here we describe a case of a woman who presented with symptoms consistent with a spinal cord injury after a traumatic fall. Her presentation and imaging were consistent with SCIWONA. The patient subsequently had rapid and complete recovery of her neurologic function. Why Should an Emergency Physician Be Aware of This? Early recognition of SCIWONA and subsequent medical management is imperative for improved outcomes for these patients. Operative treatment is rare and typically only necessary in patients with consistent spinal cord instability.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 4","pages":"Pages e338-e345"},"PeriodicalIF":1.2,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141031482","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improvising on the Fly: Comparison of a Novel Technique for Emergent Zipper Release to a Well-Established Technique in a Simulated Setting","authors":"","doi":"10.1016/j.jemermed.2024.05.001","DOIUrl":"10.1016/j.jemermed.2024.05.001","url":null,"abstract":"<div><h3>Background</h3><p>Penile skin zipper entrapment is an emergent medical condition in which the penile skin, scrotal skin, or foreskin gets caught within the teeth of a zipper or the slider itself. This can lead to complications such as urethral involvement, skin loss, or tissue necrosis. We propose a novel technique to aid in the release of entrapped skin utilizing wire cutters directed at the inferior portion of the zipper pull.</p></div><div><h3>Objectives</h3><p>To describe a novel technique to free entrapped penile skin and compare its performance to the well-established median bar technique in a simulated setting.</p></div><div><h3>Methods</h3><p>A randomized cross-over design was used to compare techniques on successful release, time to release and tissue injury using an animal model of raw chicken skin entrapped in a zipper. Statistical significance was assessed at <em>p</em> &lt; 0.05.</p></div><div><h3>Results</h3><p>Twenty-two participants were included. There was no statistically significant difference between the novel technique and the median bar technique regarding successful release (100% vs 95.5%, respectively), median time to release (29.1 vs 26.4 seconds, respectively), or frequency of tissue injury (22.7% vs 27.3%).</p></div><div><h3>Conclusion</h3><p>Performance using our novel technique for removal of penile skin from a zipper is similar to the median bar release technique regarding. Our novel technique may be a valid treatment option for the release of entrapped penile skin in a zipper mechanism in the emergency department setting.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":"67 4","pages":"Pages e351-e356"},"PeriodicalIF":1.2,"publicationDate":"2024-05-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141043120","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}