Journal of the American College of Emergency Physicians open最新文献

{"title":"Why do we need quality measures in emergency medicine?","authors":"Shamie Das MD, MBA,&nbsp;Gregg Miller MD,&nbsp;Christopher Libby MD, MPH,&nbsp;Cameron J. Gettel MD, MHS,&nbsp;Elaine Rabin MD,&nbsp;Michelle Lin MD, MPH","doi":"10.1002/emp2.13329","DOIUrl":"10.1002/emp2.13329","url":null,"abstract":"<p>Quality measures increasingly influence the delivery and reimbursement of care provided in emergency departments. While emergency physicians are accustomed to using quality measures to improve care delivery, payors, including the Centers for Medicare and Medicaid Services (CMS), are increasingly adjusting reimbursement to measure performance as a means to bend the cost curve and improve the value of healthcare services. The American College of Emergency Physicians Quality and Patient Safety Committee presents this whitepaper to guide practicing emergency physicians through the policy context of implementing measures in emergency care and understanding its impact reimbursement. This paper summarizes current CMS programs such as the merit-based incentive payment system (MIPS), MIPS value pathways, and alternative payment models and various reporting mechanisms. It is crucial for emergency physicians to understand the quality measure development process, the need for more emergency medicine-specific quality measures, and the growing significance of measure performance in the payment of emergency care.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-12-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11652395/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142856998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A case of spontaneous pneumomediastinum in a triathlete","authors":"Jack Golder OMS-II, MS","doi":"10.1002/emp2.13290","DOIUrl":"https://doi.org/10.1002/emp2.13290","url":null,"abstract":"<p>Spontaneous pneumomediastinum is an infrequent condition typically secondary to smoking, illicit drug use, or asthma. The condition often follows barotrauma or bronchial hyperactivity, causing alveolar destruction and air trapping within the mediastinum. Rarely, it may present following strenuous exercise, particularly in tall, thin males, resembling the presentation of pneumothorax. In this case, a 23-year-old male with no prior medical history presented to the emergency department with chest pain and dyspnea following intense training for a triathlon. Following a normal chest x-ray, a high-resolution computed tomography imaging revealed the presence of spontaneous pneumomediastinum. The patient was admitted for observation and managed conservatively with close monitoring for potential complications such as pneumothorax or pneumopericardium. Emergency physicians should maintain a high index of suspicion for spontaneous pneumomediastinum in patients presenting with acute chest pain and dyspnea, especially in the absence of significant comorbidities. This condition can mimic other cardiopulmonary emergencies, necessitating its inclusion in the differential diagnosis to ensure accurate and timely management.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13290","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142762393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When free air is not under the diaphragm","authors":"Andrew K. Chiu,&nbsp;Zinta Zapp MD","doi":"10.1002/emp2.13275","DOIUrl":"https://doi.org/10.1002/emp2.13275","url":null,"abstract":"<p>A 52-year-old woman presented to the emergency department with 3 days of abdominal pain. The pain began 1 day after undergoing a screening colonoscopy. On examination, her vital signs were normal and she had significant tenderness to the lower abdomen. Laboratory work revealed a white count of 22 K/µL and a normal lactate (0.8 mmol/L). An upright chest and abdominal x-ray were normal. Computed tomography (CT) of the abdomen with intravenous (IV) contrast was then performed.</p><p>Intestinal perforation is a potentially life-threatening complication that may arise from diverse etiologies, including instrumentation.<span>^1-4</span> The initial step in workup of suspected intestinal perforation is often looking for free air under the diaphragm on an upright abdominal x-ray to evaluate for pneumoperitoneum.<span>¹</span> We would not see this finding in our patient because she had pneumoretroperitoneum, where the gas pattern is different from that of pneumoperitoneum.<span>⁵</span> Ultimately, CT scan showed retroperitoneal air tracking along the aorta and inferior vena cava (IVC) (Figures 1 and 2). She underwent exploratory laparotomy with creation of a diverting end descending colostomy.</p><p>Colonoscopy-related perforation (CRP) is rare; the incidence ranges from 0.016% to 0.2% following diagnostic procedures and up to 5%, if the colonoscopy is therapeutic.<span>^2-4</span> Rectal perforations, as in this case, have been reported to have an incidence ranging from 0.003% to 0.01%.<span>^{2, 6}</span> CRP can be managed conservatively or surgically. It is important to note that up to 31% of patients with CRP present for treatment more than 24 h after their colonoscopy.<span>^{3, 4}</span></p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13275","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142749082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Older man with chronic right upper quadrant pain and vomiting","authors":"Tim A. Steck,&nbsp;Kerstin J. Neuschütz MD,&nbsp;Christian Gernhardt MD,&nbsp;Jonas Hilti MD,&nbsp;Bruno Minotti MD","doi":"10.1002/emp2.13311","DOIUrl":"10.1002/emp2.13311","url":null,"abstract":"<p>A 75-year-old man presented to the emergency department with intermittent right upper quadrant abdominal pain for 6 months and newly onset vomiting for 1 day. Two days prior, he received an abdominal ultrasound showing extensive cholecystolithiasis. Clinical examination showed mild tenderness in the right abdomen without peritonitis. Blood test results revealed moderately elevated inflammatory markers as follows: white blood cell (WBC) count 15.44 g/L and c-reactive protein (CRP)  43.4 mg/L. Liver parameters were within normal range. Bedside ultrasound was performed showing a stone-free gallbladder, non-dilated bile duct (Figure 1, panel A), and distended small bowel (Figure 1, panels B and C). Accordingly, computed tomography (CT) was performed (Figure 2).</p><p>The authors declare no conflicts of interest.</p><p>The authors received no financial support for the research, authorship, and/or publication of this article.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11563757/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142649773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Point-of-care ultrasound identifies surgical emergency, expediting care","authors":"Matthew Luce DO,&nbsp;Ryan Brandt DO,&nbsp;Joseph Betcher MD","doi":"10.1002/emp2.13327","DOIUrl":"10.1002/emp2.13327","url":null,"abstract":"<p>A 62-year-old male with a history of alcoholic cirrhosis with esophageal varices presented with a chief complaint of hematemesis and abdominal distention. Examination demonstrated ascites and a long-standing umbilical hernia. Given the patient's worsening pain and ongoing hematemesis, point-of-care ultrasound (POCUS) was utilized (Figure 1), which revealed the diagnosis, and was later confirmed with a contrast-enhanced computed tomography (CT) (Figure 2).</p><p>In this case, POCUS was utilized and accurately identified a closed-loop bowel obstruction suspended in the ascites fluid (Video 1). A contrast-enhanced CT confirmed an incarcerated umbilical hernia, and the patient was brought to the operating room for an umbilical hernia repair and small bowel release, as well as gastrointestinal consultation for possible esophageal variceal bleeding.</p><p>The current gold-standard imaging modality for small bowel obstruction (SBO) is CT imaging. This case demonstrates the utility of POCUS in the diagnosis of SBO at bedside (Video 2). Considering his extensive history of high-risk cirrhosis leading to hematemesis and a challenging abdominal examination revealing long-standing ascites, treating physicians may face the risk of anchoring bias, potentially narrowing their focus on the possibility of esophageal variceal bleeding. POCUS quickly revealed the additional pathology, with the obstruction evident within the ascites. POCUS has also demonstrated a significant reduction in time to imaging completion when utilized for bowel obstructions, potentially leading to shorter time to surgical intervention.<span>¹</span> Depending on certain clinical factors, some patients may be able to forego CT scans after demonstration of an obstruction process on POCUS.<span>²</span></p><p>All authors contributed significantly to the preparation of this report.</p><p>The authors declare they have no conflicts of interest.</p><p>The authors received no specific funding for this work.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11549060/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142634223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Complication of post-lumbar puncture","authors":"Pranjal Rai MBBS,&nbsp;Vasundhara Patil MD","doi":"10.1002/emp2.13308","DOIUrl":"10.1002/emp2.13308","url":null,"abstract":"<p>A 17-year-old male with juvenile nasal angiofibroma and intracranial extension underwent tumor excision with dural repair and skull base defect reconstruction using flap, presented with meningismus a year later. Initial computed tomography (CT) scan showed features of meningitis in the form of diffuse sulcal effacement and subtle leptomeningeal enhancement (Figure 1). A lumbar puncture (LP) was performed to obtain cerebral spinal fluid (CSF) for microbiology and biochemical tests. Deterioration of his neurological status approximately 1-week post-procedure prompted an magnetic resonance imaging (MRI) evaluation that revealed multiple susceptibility artifacts on susceptibility-weighted sequences (See Figure 2A and B), which corresponded to pneumocephalus, pneumoventricle, and pneumocistern on CT (See Figure 2C and D). Nasal endoscopy and MRI cisternogram were negative for any fistula. The patient improved symptomatically after 2 weeks with conservative management. Follow-up study showed complete resolution of the findings.</p><p>Initial CT being negative for air (Figure 1), followed by LP-induced pneumocephalus, postulates two possible theories. First is a possible occult, one-way dural fistula at the surgical site leading to slow air entry post-LP into the subarachnoid space due to the over-drainage of CSF, which may have led to intracranial hypotension. This fistula was not detected on the endoscopy or MR cisternogram possibly because the procedures were performed without pressurization of air spaces. The second possibility is accidental injection of air into the subarachnoid space during LP.<span>¹</span> Considering the amount of air in this case, the second mechanism appears more likely (See Figure 2</p><p>Subarachnoid pneumocephalus is mostly asymptomatic unless large and resolves spontaneously within 1–2 weeks. Treatment with high concentration of oxygen may also hasten recovery.<span>²</span> While raised intracranial pressure is not an absolute contraindication to lumbar puncture, a controlled drainage with minimum effective amount should be performed in these patients as over-draining CSF may lead to side effects such as post-dural puncture headaches, or air entry into the subarachnoid space through the spinal needle or any indolent surgical site fistula.</p><p>The authors declare no conflicts of interest.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543629/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142634216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Management of factor Xa inhibitor–related traumatic non-intracranial bleeding events with andexanet alfa or four-factor prothrombin complex concentrate in a US multicenter observational study","authors":"Paul P. Dobesh PharmD,&nbsp;Craig I. Coleman PharmD,&nbsp;Mark Danese PhD,&nbsp;Eva Lesén PhD,&nbsp;Raymond C. Chang MBA, MS,&nbsp;Onivefu Odelade BPharm, MSc,&nbsp;Gregory J. Fermann MD","doi":"10.1002/emp2.13333","DOIUrl":"10.1002/emp2.13333","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>This study describes clinical characteristics and management strategies for patients with factor Xa (FXa) inhibitor–related traumatic non-intracranial bleeds who were treated with andexanet alfa or four-factor prothrombin complex concentrate (4F-PCC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>An observational cohort study (ClinicalTrials.gov Identifier: NCT05548777) was conducted using electronic health records from 354 US hospitals. Included patients were hospitalized with rivaroxaban- or apixaban-related bleeding, had received andexanet alfa or 4F-PCC treatment during their hospitalization, and were discharged between May 2018 and September 2022. This analysis was performed in the subgroup of patients with traumatic non-intracranial critical compartment/non-compressible bleeds or other traumatic bleeds.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The study population included 250 patients (andexanet alfa, <i>n</i> = 116; 4F-PCC, <i>n</i> = 134). Critical compartment bleeds were the most common (86.8%), with retroperitoneal bleeds the most common subtype (30.9%). Most patients were admitted via the emergency department (82.0%). The median time from presentation to reversal/replacement treatment was 2.7 (interquartile range, 1.2, 6.6) h. For patients treated with andexanet alfa, 63.8% were administered the low-dose regimen. For 4F-PCC, a median of 2000 total units was administered per patient. Other treatment strategies used included intravenous fluids (26.0%), fresh frozen plasma (16.0%), and packed red blood cells (13.2%). Prior to hospital discharge, oral anticoagulants were restarted in 20.4% of patients. Overall, 25 (10.0%) patients died in hospital.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>This analysis provides insights into the clinical characteristics and management strategies, including time to treatment, for patients treated with andexanet alfa or 4F-PCC while hospitalized for FXa inhibitor–related traumatic bleeds.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543631/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142634221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Construction and performance of a clinical prediction rule for ureteral stone without the use of race or ethnicity: A new STONE score","authors":"Christopher L. Moore MD,&nbsp;Cary P. Gross MD,&nbsp;Louis Hart MD,&nbsp;Annette M. Molinaro PhD,&nbsp;Deborah Rhodes MD,&nbsp;Dinesh Singh MD,&nbsp;Cristiana Baloescu MD","doi":"10.1002/emp2.13324","DOIUrl":"10.1002/emp2.13324","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>The original STONE score was designed to predict the presence of uncomplicated renal colic and the corresponding absence of alternate serious etiologies. It was retrospectively derived and prospectively validated and resulted in five variables: Sex (male gender), Timing (acute onset of pain), “Origin” (non-Black race), Nausea/vomiting (present), and Erythrocytes (microscopic hematuria). With recent increased awareness of the potential adverse impacts of including race (a socially constructed identity) in clinical prediction rules, we sought to determine if a revised STONE score without race could be constructed with similar diagnostic accuracy.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We used data from the original STONE score that utilized retrospective data on patients with confirmed kidney stone by computed tomography (CT) to derive a clinical prediction rule as well as prospective data to validate the score. These data were used to construct a revised STONE score after removing race as a variable. We performed univariate and multivariable logistic regression and compared the old and new STONE scores (including multivariable, integral, and three-level risk) using the area under the receiver operating characteristic curve (AUC) and misclassification rates.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>After the elimination of race, multivariable logistic regression revealed that gross hematuria was the next strongest feasible variable for the prediction of ureteral stone. This was incorporated into a revised STONE score by substituting “obvious hematuria” for “origin” (formerly race). The revised STONE score had similar predictive accuracy to the original STONE score: AUC 0.85 versus 0.86 (95% confidence interval [CI]: 0.82–0.87 and 0.79–0.93); misclassification rates were also unchanged, 0.23 versus 0.23 (95% CI: 0.20–0.25 and 0.20–0.25).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>We modified the STONE score to remove race and include “obvious hematuria” without losing clinical accuracy. Considering the potential adverse effects of propagating racial bias in clinical algorithms, we recommend using the revised STONE score. Future research could investigate the potential contributions of social drivers of health (SDOH) to the diagnosis of kidney stone.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11543628/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142634219","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Rationale and development of a prehospital goal-directed bundle of care to prevent rearrest after return of spontaneous circulation","authors":"David G. Dillon MD, PhD,&nbsp;Juan Carlos C. Montoy MD, PhD,&nbsp;Nichole Bosson MD, MPH,&nbsp;Jake Toy DO, MS,&nbsp;Senai Kidane MD,&nbsp;Dustin W. Ballard MD, MBE,&nbsp;Marianne Gausche-Hill MD,&nbsp;Joelle Donofrio-Odmann DO,&nbsp;Shira A. Schlesinger MD, MPH,&nbsp;Katherine Staats MD,&nbsp;Clayton Kazan MD, MS,&nbsp;Brian Morr BS, MICP,&nbsp;Kristin Thompson RN,&nbsp;Kevin Mackey MD,&nbsp;John Brown MD, MPA,&nbsp;James J. Menegazzi PhD,&nbsp;the California Resuscitation Outcomes Consortium","doi":"10.1002/emp2.13321","DOIUrl":"10.1002/emp2.13321","url":null,"abstract":"<p>In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11536478/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142585254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A woman with sudden unilateral vision loss","authors":"Areeba Abid MD,&nbsp;Michelle P. Lin MD,&nbsp;Elizabeth Cox MD,&nbsp;Timothy J. Batchelor MD","doi":"10.1002/emp2.13337","DOIUrl":"https://doi.org/10.1002/emp2.13337","url":null,"abstract":"&lt;p&gt;A 60-year-old female with a history of breast cancer in remission presented to the emergency department with 1 day of acute onset left eye visual changes, which she described as “shadows” and “tunnel-like.” She reported mild pain and “stinging” with extraocular movements of the left eye. Physical exam demonstrated relative afferent pupillary defect in the left eye, with visual field defects in the infranasal and supratemporal regions. The patient had normal intraocular pressure (IOP) and 20/20 corrected central vision. Ocular point-of-care ultrasound of the left eye was performed, demonstrating “spot sign” (Figure 1, Video 1). The presumptive diagnosis was corroborated by a comprehensive ocular examination by ophthalmology. She was ultimately discharged to outpatient follow up on dual-antiplatelet therapy.&lt;/p&gt;&lt;p&gt;&lt;i&gt;Central retinal artery occlusion&lt;/i&gt; (CRAO) typically presents with painless loss of vision,&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; resulting from sudden blockage of the central retinal artery. This is an ocular emergency and a stroke equivalent, with retinal hypoperfusion causing rapidly progressive retinal damage and vision loss.&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;“Spot sign” is a hyperechoic focus sometimes seen posterior to the globe within the optic nerve sheath, indicative of a calcified embolus from atherosclerotic plaques. Transbulbar ultrasound is valuable for the initial diagnosis and workup of CRAO because it helps to elucidate whether occlusion is secondary to thrombus or calcified embolus, with positive spot sign associated with decreased effectiveness of thrombolysis. The absence of spot sign may help to identify patients more likely to benefit from thrombolytic treatment.&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt;&lt;/p&gt;&lt;p&gt;We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. In so doing, we confirm that we have followed the regulations of our institutions concerning intellectual property and patient confidentiality. We understand that the corresponding author is the sole contact for the editorial process (including editorial manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions, and final approval of proofs.&lt;/p&gt;&lt;p&gt;We confirm that we have provided a current, correct email address which is accessible ","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":"5 6","pages":""},"PeriodicalIF":1.6,"publicationDate":"2024-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/emp2.13337","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142540829","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}