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

{"title":"Letter to the Editor—Response to “Opioid-related xylazine toxicity manifesting as myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema”","authors":"Anthony Spadaro MD, MPH,&nbsp;Jennifer S. Love MD,&nbsp;Lewis S. Nelson MD, MBA,&nbsp;Howard A. Greller MD","doi":"10.1002/emp2.13258","DOIUrl":"10.1002/emp2.13258","url":null,"abstract":"<p>To the Editors,</p><p>We commend the authors on their presentation of “Opioid-related xylazine toxicity manifesting as myonecrosis, rhabdomyolysis, multifocal ischemic cerebral infarcts, and cerebral edema”.<span>¹</span></p><p>However, we have significant concerns regarding their attribution of the adverse effects to xylazine. The case description is identical to that of a hypoxic, multiorgan system insult resulting from an opioid overdose, including liver injury, rhabdomyolysis, and cerebral infarcts. While the authors appropriately note that the unregulated fentanyl supply is increasingly adulterated with xylazine, “xylazine overdose” is currently always a xylazine–fentanyl overdose.<span>²</span> Therefore, the contribution of fentanyl in overdose victims cannot be overlooked or underestimated, and especially given hearing loss, it is far more likely that the patient's injuries were due to fentanyl.<span>³</span></p><p>The authors hypothesize that xylazine toxicity resulted in hemodynamic changes that contributed to microvascular constriction and infarcts. They cite animal studies or case studies of intentional xylazine overdose, which are not clinically analogous to human exposure to fentanyl adulterated with xylazine. Interestingly, patients with consequential xylazine-adulterated fentanyl exposures may be relatively hemodynamically stable. In a study of patients with such overdoses in whom xylazine was detected, there was no increase in the incidence or degree of bradycardia, coma, or need for ventilatory support.<span>⁴</span> In fact, xylazine-exposed patients had lower rates of cardiopulmonary arrest. A potential explanation for this finding is that due to the addition of xylazine to the street product, they were exposed to less fentanyl overall.</p><p>The authors rely on urine drug screen (UDS) results to support that xylazine is the cause of the patient's presentation. Fentanyl and xylazine were detected on the UDS; however, there was no quantitative measurement of either fentanyl or xylazine to explain their relative contributions to the outcome. Regardless, because the detection window of a xylazine UDS is not known, it is not possible to know the time of last use or the temporal relationship between xylazine-adulterated fentanyl use and the development of clinical effects. There may be utility in adding xylazine to a UDS for epidemiological or research purposes or for educating patients on the contents of the unregulated drug supply, but there is no clear clinical utility for the management of patients with acute drug intoxication. Furthermore, the xylazine UDS may lead to premature diagnostic closure with a time-sensitive conditions, such as altered mental status.<span>⁵</span> Although the emergence of xylazine in the unregulated drug supply is a public health concern, it should not distract from the fact that fentanyl is the major contributor to drug overdose deaths and t","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11306281/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141908571","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":"Intersectional trends in child and adolescent suicide-related emergency department encounters in Florida (2016‒2021)","authors":"Laura M. Prichett MHS, PhD,&nbsp;Claudia Paszek BA,&nbsp;Emily E. Haroz MHS, PhD","doi":"10.1002/emp2.13257","DOIUrl":"10.1002/emp2.13257","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Emergency department (ED) visits resulting from suicidal thoughts and behaviors have increased at alarming rates among youth in the United States in recent years. Understanding trends among specific racial, ethnic, gender, and/or age subgroups can provide the foundation for tailored solutions for those with the greatest need for support.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Using data from the Florida State Emergency Department Database from 2016 to 2021, we calculated annual rates of ED suicide-related diagnoses per 1000 young people aged 8‒21 years. We explored annual trends by age and intersectional race/ethnicity and sex subgroups. Additionally, we examined subgroup-specific stratified percent changes from 2016 to 2019 and 2016 to 2021.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Among 8‒12-year olds, the highest rates of suicide-related ED encounters occurred among Black males and females and this trend was steady over time. Among 13‒21-year-old patients, Black and White females displayed the highest rates of suicide-related ED encounters across 2016‒2021, and all subgroups experienced a slight decline in 2020 and 2021. Rates generally increased between 2016 and 2019, with the largest percent increase (10.6%) occurring among Black females aged 18‒21 years, whereas there was a trend of decreased rates among most subgroups between 2019 and 2021.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Across all years and age groups, Black females showed consistently higher rates of suicide-related ED encounters than almost any other subgroup, supporting previous research that Black adolescent females may be disproportionately suffering from the mental health crisis faced by young people. Furthermore, preteen Black males need additional mental health support, as do adolescent and young adult White females.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11304895/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141903875","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":"Man with convulsive syncope","authors":"Satheesh Gunaga DO,&nbsp;Dennis Smythe BS,&nbsp;Nathaniel Shearer DO,&nbsp;Mustafa Hashem MD,&nbsp;Abe Al-Hage DO","doi":"10.1002/emp2.13249","DOIUrl":"10.1002/emp2.13249","url":null,"abstract":"<p>A 48-year-old male collapsed during a physical therapy session at a rehab facility. Bystanders reported the patient lost consciousness briefly with abnormal jerking movements, bowel incontinence, and returned to baseline within 1 minute. His recent medical history includes a right tibial fracture and ureterolithiasis requiring ureteral stenting. In the emergency department (ED), he was tachycardic but hemodynamically stable, with mildly elevated troponin and d-dimer levels.</p><p>Submassive pulmonary embolism (PE) was revealed by computed tomography (CT) pulmonary angiography (Figure 1). Despite hemodynamic stability, this patient displayed right heart strain findings on both electrocardiogram and CT scans, with mildly elevated cardiac biomarkers. These findings were concerning for severe thrombotic burden and the patient underwent urgent pulmonary thrombectomy (Figure 2). Much can be learned from this case. First, it highlights that not all that shakes are seizures. Myoclonic jerking, often seen in syncope patients, can often be mistaken for seizure activity by bystanders, leading to potential anchoring bias in ED diagnosis.<span>¹</span> Second, syncope should not be viewed as a definitive diagnosis, but rather as a symptom. It is essential to remember that syncope can be the primary presenting symptom in severe conditions such as PE, ruptured ectopic pregnancies, abdominal aortic aneurysms, gastrointestinal bleeds, and acute myocardial infarctions.<span>²</span> Finally, in patients presenting with submassive PE, using simplified pulmonary embolism severity index (sPESI) scores &gt;1 to identify high-risk PE patients, then strategically collaborating with your institution's PE rescue team can facilitate prompt clot removal (Figure 3).<span>³</span> Recent pulmonary thrombectomy trials demonstrate reduction in mortality and long-term thrombotic burdens of PE.<span>^{4, 5}</span></p><p>The authors declare no conflict of interest.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299247/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141895181","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":"Does initiating care in alternate care sites decrease time to disposition in the emergency department?","authors":"Alyssa Mangino MD,&nbsp;Lakshman Balaji BDS, MPH,&nbsp;Bryan Stenson MD,&nbsp;Larry A. Nathanson MD,&nbsp;David Chiu MD, MPH,&nbsp;Shamai A. Grossman MD, MS","doi":"10.1002/emp2.13195","DOIUrl":"10.1002/emp2.13195","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>During the coronavirus disease 2019 (COVID-19) pandemic surge, alternate care sites (ACS) such as the waiting room or hospital lobby were created amongst hospitals nationwide to help alleviate emergency department (ED) overflow. Despite the end of the pandemic surge, many of these ACS remain functional given the burden of prolonged ED wait times, with providers now utilizing the waiting room or ACS to initiate care. Therefore, the objective of this study is to evaluate if initiating patient care in ACS helps to decrease time to disposition.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Retrospective data were collected on 61,869 patient encounters presenting to an academic medical center ED. Patients with an emergency severity index (ESI) of 1 were excluded. The “pre-ACS” or control data consisted of 38,625 patient encounters from September 30, 2018 to October 1, 2019, prior to the development of ACS, in which the patient was seen by a physician after they were brought to an assigned ED room. The “post-ACS” study cohort consisted of 23,244 patient encounters from September 30, 2022 to October 1, 2023, after the initiation of ACS, during which patients were initially seen by a provider in an ACS. ACS at this institution included the three following areas: waiting room, ambulance waiting area, and a newly constructed ACS that was built next to the ED entrance on the first floor of the hospital. The newly constructed ACS consisted of 16 care spaces each containing an upright exam chair with dividers between each care space. Door-to-disposition time (DTD) was calculated by identifying the time when the patient entered the ED and the time when disposition was decided (admission requested or patient discharged). Using regression analysis, we compared the two data sets to determine significant differences among DTD time.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The largest proportion of encounters were among ESI 3 patients, that is, 56.1%. There was a significant increase in median DTD for ESI 2 and 3 patients who were seen initially in an ACS compared to those who were not seen until they were in an assigned ER room. Specifically, there was a median increase of 40.9 min for ESI 2 patients and 18.8 min for ESI 3 patients who were seen initially in an ACS (<i>p</i> &lt; 0.001). There was a 29-min decrease in median DTD for ESI 5 patients who were seen in ACS (<i>p</i> = 0.09).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Initiating patient care earlier in ACS did not appear to decrease DTD time for patients","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11298685/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141894959","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":"Recurrent, atraumatic acute compartment syndrome secondary to IgA vasculitis: A case report","authors":"Mel Ebeling BS,&nbsp;Blake Hudson MD","doi":"10.1002/emp2.13270","DOIUrl":"10.1002/emp2.13270","url":null,"abstract":"<p>Acute compartment syndrome is a surgical emergency requiring rapid recognition in the emergency department to minimize morbidity and mortality. It is most commonly caused by traumatic extremity fractures, which account for about 75% of cases. Atraumatic acute compartment syndrome is substantially less common with current evidence mostly limited to case reports, and diagnosis is made more challenging by the absence of an obvious traumatic injury. We present the case of a young adult female patient with IgA vasculitis who developed recurrent, atraumatic acute compartment syndrome and was successfully managed with prompt fasciotomy. This is the first case of spontaneous intramuscular hemorrhage, a rare sequela of IgA vasculitis, leading to recurrent, atraumatic acute compartment syndrome. This case highlights the importance of both a thorough physical exam and maintaining a high suspicion for acute compartment syndrome in the absence of injury to ensure patients receive prompt surgical evaluation for definitive care.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299245/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141894960","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":"No evidence for xylazine causing cerebral infarcts","authors":"Kim-Long R. Nguyen MD MBA,&nbsp;Michael E. Mullins MD","doi":"10.1002/emp2.13263","DOIUrl":"10.1002/emp2.13263","url":null,"abstract":"<p>Dear Editor,</p><p>We have read with great interest the case report by Nwodim et al.<span>¹</span> However, the authors’ excitement about xylazine led them to overlook the evidence and to ignore other more likely causes of the patient's multiple findings and difficult course.</p><p>The authors assert that the patient had xylazine toxicity, which was never evident in this case. While her urine drug screen was qualitatively positive for fentanyl and xylazine, detection alone does not prove toxicity as it is a clinical diagnosis. In particular, the patient had tachycardia instead of bradycardia, the latter of which may distinguish xylazine effect from opioid effect.</p><p>Although the patient had a history of bacteremia, the authors excluded infectious embolic based upon negative blood cultures and a transthoracic echocardiogram that did not demonstrate vegetations. However, the authors appear to overlook the possibility of emboli forming from insoluble excipients or adulterants in the injected material.</p><p>It also likely that the patient's injection of drugs “into a blood vessel in her neck” resulted in carotid arterial injury. The cited article described cerebral injury from intracarotid injection of 0.3 mL of a mixture of ketamine, xylazine, and butorphanol in an alpaca (<i>Vicugna pacos</i>).<span>²</span> The authors implicated the vascular injury of the inadvertent carotid puncture and not xylazine as the direct cause of resulting pathology.<span>²</span></p><p>Furthermore, the patient's case appears similar to cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion (CHANTER) syndrome.<span>³</span> The authors offer no evidence to exclude this.</p><p>The authors suggest that the patient's cerebral injuries resulted from a transient and scattered microvascular intracerebral constriction with resultant reperfusion from subsequent vasodilation. They offer no evidence that xylazine produces scattered regions of focal arterial constriction or the rebound reperfusion.</p><p>The authors also blame xylazine for the patient's transient hearing loss. However, this is inconsistent with magnetic resonance imaging findings that did not reveal infarcts to explain deafness. There are no reports credibly attributing transient hearing loss to illicit xylazine use, but opioid-associated hearing loss is well recognized.<span>⁴</span> The exact mechanism remains uncertain, but most cases have partial or complete resolution, as observed in this case.</p><p>Xylazine has an inconsistent association with necrotic skin wounds that may or may not correlate with drug injection sites. A literature review by Ruiz-Colón et al. yielded only case reports and no available evidence to explain the mechanism of injury.<span>⁵</span> However, whether and how xylazine might be the principal cause of such wounds remain uncertain.</p><p>The patient described by Nwodim et al. had a co","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299244/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141895182","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":"Young woman with dyspnea and neck swelling","authors":"Jen-Ping Chen MD,&nbsp;Cheng-Han Chen MD, PhD","doi":"10.1002/emp2.13247","DOIUrl":"10.1002/emp2.13247","url":null,"abstract":"<p>A healthy 19-year-old woman presented to the emergency department with a 7-day history of dyspnea and a 1-day history of neck swelling. She reported regular participation in boxing and receiving sports massage. Physical examination revealed bilateral neck swelling with crepitus. The emergency physician performed a neck soft tissue radiograph (Figure 1) and confirmed the diagnosis by a chest computed tomography (Figures 2 and 3).</p><p>Spontaneous pneumomediastinum, also referred to as Hamman's syndrome,<span>¹</span> is characterized by the presence of air in the mediastinum without an apparent etiology. This condition arises from alveolar rupture and commonly resolves spontaneously.<span>²</span> Patients presenting with spontaneous pneumomediastinum and no absent additional complications, such as vomiting, typically undergo a brief period of observation and receive symptomatic care.<span>³</span> Surgical interventions may be warranted for individuals exhibiting clear evidence of mediastinal organ injury.<span>⁴</span> Although spontaneous pneumomediastinum is mainly treated with observation, delayed diagnosis may lead to fatal complications, such as infection or tension pneumothorax.<span>⁵</span></p><p>No identifiable perforation site was noted during the esophagogastroduodenoscopy of our patient. The patient underwent conservative management, and subsequent radiography after 1 week indicated resolution of the pneumomediastinum. She was discharged without any adverse outcomes.</p><p>The authors have no conflicts of interest to report.</p><p>The authors have no professional or financial affiliations.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11299246/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141894961","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":"An intubation technique using hyperangulated video laryngoscopy and a DuCanto suction catheter preloaded with a bougie: A case report with a video demonstration","authors":"Samuel G. Rouleau MD,&nbsp;Dale Till MD,&nbsp;Paul Copperman DO,&nbsp;Verena Schandera MD,&nbsp;Erik G. Laurin MD","doi":"10.1002/emp2.13238","DOIUrl":"10.1002/emp2.13238","url":null,"abstract":"<p>Video laryngoscopy outperforms direct laryngoscopy for successful orotracheal intubation in the emergency department. When performing video laryngoscopy, emergency physicians may use a standard geometry blade or a hyperangulated blade. Hyperangulated video laryngoscopy is easier when using a rigid hyperangulated stylet instead of a standard malleable stylet. The angulation of the hyperangulated blade makes it difficult to use an endotracheal tube (ETT) introducer (“bougie”). We describe a case report using a DuCanto suction catheter (SSCOR) with a preloaded bougie to perform orotracheal intubation during hyperangulated video laryngoscopy. An adult patient presented to the emergency department in status epilepticus and was intubated for airway protection. Hyperangulated video laryngoscopy was performed with a LoPro S4 (GlideScope) blade; a DuCanto suction catheter was used to deliver a bougie through the vocal cords. The bougie was advanced down the trachea, and the DuCanto suction catheter was removed. The bougie successfully delivered a size 8.0 ETT. Visualization of the larynx with hyperangulated video laryngoscopy is usually easy, but ETT delivery into the trachea can be challenging. Rigid hyperangulated stylets were created to facilitate ETT delivery, but these stylets are expensive and often not available. Traditional teaching says that a bougie cannot be used while intubating with a hyperangulated blade. This case report describes a method to deliver a bougie via a DuCanto suction catheter during hyperangulated video laryngoscopy. It allows for the use of a bougie with a hyperangulated blade and offers a technique to perform hyperangulated video laryngoscopy without a rigid stylet.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-08-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11297598/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141891133","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":"Woman with fever and epigastric pain","authors":"Ping-Shih Chen MD,&nbsp;Kuo-Chih Chen MD,&nbsp;Chee-Fah Chong MS, MD","doi":"10.1002/emp2.13246","DOIUrl":"10.1002/emp2.13246","url":null,"abstract":"<p>A 54-year-old female without a medical history presented to the emergency department (ED) with fever and epigastric pain for 2 days. Laboratory findings showed a white blood cell count of 18,400/µL and a C-reactive protein level of 20.47 mg/dL (normal &lt;0.5 mg/dL). Point-of-care ultrasound (POCUS) demonstrated a hypoechoic focus in the left hepatic lobe adjacent to the gastric antrum. Furthermore, a hyperechoic and linear structure, measuring 3.57 cm in length was identified, connecting those two structures (Figure 1; Video 1).</p><p>Abdominal computed tomography (CT) was performed and confirmed the diagnosis (Figure 2). Exploratory laparotomy revealed perforation of the stomach (pre-pyloric) with the fishbone penetrating the liver, which was then removed surgically (Figure 3). The patient recovered well without any complications.</p><p>Although rare, liver abscesses caused by ingested fishbones can occur. CT scans are the current diagnostic standard for such cases.<span>¹</span> To the best of our knowledge, this is the first reported case in the English literature where POCUS has been utilized to diagnose a liver abscess caused by a fish bone. Using POCUS to determine if a liver abscess is caused by a foreign body is crucial, since its treatment often requires surgery,<span>²</span> as demonstrated in this case.</p>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11289672/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141861863","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":"Alcohol use is associated with intracranial hemorrhage in older emergency department head trauma patients","authors":"Alexander Zirulnik MD, MPH,&nbsp;Shan Liu MD, SD,&nbsp;Mike Wells MBBCh, PhD,&nbsp;Scott M. Alter MD, MBA,&nbsp;Gabriella Engstrom PhD,&nbsp;Joshua J. Solano MD,&nbsp;Lisa M. Clayton DO, MBS,&nbsp;Mark Reiter MD, MBA,&nbsp;Patrick G. Hughes DO, MEHP,&nbsp;Lara Goldstein MBBCh, PhD,&nbsp;Richard D. Shih MD","doi":"10.1002/emp2.13245","DOIUrl":"10.1002/emp2.13245","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>Falls are common in adults aged 65 years and older and are the leading cause of traumatic brain injuries in this age group. Alcohol use may increase the risk of falls as well as the severity of resultant injuries. The aim of this study was to examine the association between self-reported alcohol use and the prevalence of intracranial hemorrhage (ICH) in this patient group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>This was a secondary analysis of the Geriatric Head Trauma Short Term Outcomes Project (GREAT STOP), a study of older adults with blunt head trauma from a fall. We determined the characteristics of every fall event, including patient demographics and medical history, and clinical signs and symptoms related to head trauma. Self-reported alcohol use was categorized as none, occasionally, weekly, or daily. We defined ICH as any acute ICH detected by computed tomography scan. We evaluated the association between alcohol use frequency and ICH, adjusted for patient factors and head injury risk factors.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 3128 study participants, 18.2% (<i>n</i> = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use. ICH was more common in patients who used alcohol (20.5%, 22.0%, and 25.1% for occasional, weekly, and daily alcohol users, respectively, vs. 12.0% for non-users, <i>p</i> &lt; 0.001). The frequency of alcohol use was independently associated with ICH, adjusted for patient and head injury risk factors. The adjusted odds ratios (with 95% confidence intervals) for occasional, weekly, and daily alcohol users increased from 2.0 (1.5‒2.8) to 2.1 (1.1‒4.1) and 2.5 (1.7‒3.6), respectively, and showed the characteristics of dose‒response effect.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.</p>\u0000 </section>\u0000 </div>","PeriodicalId":73967,"journal":{"name":"Journal of the American College of Emergency Physicians open","volume":null,"pages":null},"PeriodicalIF":1.6,"publicationDate":"2024-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11289673/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141861862","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}