Emergency Medicine Commons^™

Case Report: The Heart Breaking Tale Of Takotsubo In The Ed, Richard Baluyot, James Espinosa, Alan Lucerna, Sergey Medlenov, Joseph Pagano, Bhumi Shah

Rowan-Virtua Research Day

Chest pain is one of the most common chief complaints that emergency room physicians deal with on a daily basis. Here we present a rare cause of chest pain on a patient diagnosed with takotsubo cardiomyopathy. This is a condition that has been on the rise since its initial discovery and therefore clinicians should consider this on their differential when assessing patients with chest pain, especially postmenopausal women.

Celiac Artery Aneurysm: A Rare Cause Of Abdominal Pain, Duwayne Campbell, Wayne Tamaska, Kevin Dwyer

Rowan-Virtua Research Day

Celiac artery aneurysm is a very rare vascular lesion accounting for only 5.1% of all splanchnic artery aneurysms. Etiology for celiac artery aneurysm includes, but not limited to, infectious diseases, atherosclerosis, trauma, congenital conditions such as median arcuate ligament syndrome and iatrogenic causes.

Etiology for abdominal pain is extensive. Patients should be evaluated for both intra-abdominal and extra-abdominal causes for pain, as presentations of a different pathophysiology vary widely. CT scan has become a mainstay part of the work for abdominal pain in the Emergency department, and often elicit pathologies that would otherwise be missed on blood work and other …

Stroke Network Of Wisconsin (Snow) Scale Predicts Large Vessel Occlusion Stroke In The Prehospital Setting, Kessarin Panichpisal, Sarah Erpenbeck, Paul Vilar, Reji P. Babygirija, Maharaj Singh, M. Riccardo Colella, Richard A. Rovin

Journal of Patient-Centered Research and Reviews

Purpose: In previous trials, the Stroke Network of Wisconsin (SNOW) scale accurately predicted large vessel occlusion (LVO) stroke in the hospital setting. This study evaluated SNOW scale performance in the prehospital setting and its ability to predict LVO or distal medium vessel occlusion (DMVO) in patients suspected of having acute ischemic stroke (AIS), a scenario in which transport time to an endovascular treatment-capable facility (ECSC) is critical.

Methods: All potential AIS patients with last-known-well time of ≤ 24 hours were assessed by Milwaukee County Emergency Medical Services for LVO using SNOW. Patients with a positive SNOW score were transferred to …

Clinical Characteristics, Risk Factors, And Outcomes Among A Large Midwestern U.S. Cohort Of Patients Hospitalized With Covid-19 Prior To Vaccine Availability, Viviana Zlochiver, Ana Cristina Perez Moreno, Michael Peterson, Khalil Odeh, Ashley Mainville, Katherine Busniewski, Jon Wrobel, Mohamed Hommeida, Blair Tilkens, Payal Sharma, Hlu Vang, Sara Walczak, Fekadesilassie Moges, Kritika Garg, A. Jamil Tajik, Suhail Q. Allaqaband, Tanvir Bajwa, M. Fuad Jan

Journal of Patient-Centered Research and Reviews

Purpose: The COVID-19 pandemic posed unprecedented demands on health care. This study aimed to characterize COVID-19 inpatients and examine trends and risk factors associated with hospitalization duration, intensive care unit (ICU) admission, and in-hospital mortality.

Methods: This retrospective study analyzed patients with SARS-CoV-2 infection hospitalized at an integrated health system between February 2, 2020, and December 12, 2020. Patient characteristics and clinical outcomes were obtained from medical records. Backward stepwise logistic regression analyses were used to identify independent risk factors of ICU admission and in-hospital mortality. Cox proportional hazards models were used to evaluate relationships between ICU admission and in-hospital …

Identifying The 'Vulnerable Plaque' In Asymptomatic Carotid Artery Disease Patients, Zia Ur Rehman

Department of Surgery Docs

No abstract provided.

Quantification Of Infarct Core Signal Using Ct Imaging In Acute Ischemic Stroke, Uma Maria Lal-Trehan Estrada, Grant Meeks, Sergio Salazar-Marioni, Fabien Scalzo, Mudassir Farooqui, Juan Vivanco-Suarez, Santiago Ortega Gutierrez, Sunil A Sheth, Luca Giancardo

Faculty, Staff and Student Publications

In stroke care, the extent of irreversible brain injury, termed infarct core, plays a key role in determining eligibility for acute treatments, such as intravenous thrombolysis and endovascular reperfusion therapies. Many of the pivotal randomized clinical trials testing those therapies used MRI Diffusion-Weighted Imaging (DWI) or CT Perfusion (CTP) to define infarct core. Unfortunately, these modalities are not available 24/7 outside of large stroke centers. As such, there is a need for accurate infarct core determination using faster and more widely available imaging modalities including Non-Contrast CT (NCCT) and CT Angiography (CTA). Prior studies have suggested that CTA provides improved …

Endovascular Treatment And Outcomes For Femoropopliteal In-Stent Restenosis: Insights From The Xlpad Registry, Michael H Vu, Glaiza-Mae Sande-Docor, Yulun Liu, Shirling Tsai, Mitul Patel, Chris Metzger, Mehdi H Shishehbor, Emmanouil S Brilakis, Nicolas W Shammas, Peter Monteleone, Subhash Banerjee

Faculty, Staff and Student Publications

BACKGROUND: There is limited "real-world" evidence examining treatment modalities and outcomes in patients with symptomatic peripheral arterial disease undergoing endovascular treatment of femoropopliteal (FP) in-stent restenosis (ISR).

MATERIALS AND METHODS: We compared outcomes in 2,895 patients from the XLPAD registry (NCT01904851) between 2006 and 2019 treated for FP ISR (

RESULTS: ISR patients were more frequently on antiplatelet (94.5% vs 89.4%,

CONCLUSION: Atherectomy and DCB are more frequently used to treat FP ISR lesions. Patients with FP ISR have more intraprocedural distal embolization, higher repeat revascularization procedures, and lower freedom from MALE at 1 year.

The Role Of Pre-Participation Exams In Identifying Student Athletes At Risk For Sudden Cardiac Arrest, Elizabeth Frey

Honors Projects

Sudden cardiac arrest (SCA) is the leading cause of death in young student athletes (Drezner et al., 2007). With athletes being recognized as some of the healthiest members of society, a catastrophic event like this can stimulate debate over pre-participation screening and appropriate emergency actions. With 55-80% cases of sudden cardiac death (SCD) being asymptomatic before the event (Drezner et al., 2007), looking into how well pre-participation screenings identify at risk individuals becomes much more important. This project investigates to what extent pre-participation physicals (PPE) can be improved to better identify student athletes at risk for sudden cardiac death and …

A Simplified Approach To Identification Of Risk Status In Patients With Atherosclerotic Cardiovascular Disease, Aparna Sajja, Hsin-Fang Li, Kateri J Spinelli, Amir Ali, Salim S Virani, Seth S Martin, Ty J Gluckman

Faculty, Staff and Students Publications

OBJECTIVE: The 2018 American Heart Association/American College of Cardiology (AHA/ACC) Blood Cholesterol Guideline recommendation to classify patients with atherosclerotic cardiovascular disease (ASCVD) as very high-risk (VHR) vs not-VHR (NVHR) has important implications for escalation of medical therapy. We aimed to define the prevalence and clinical characteristics of these two groups within a large multi-state healthcare system and develop a simpler means to assist clinicians in identifying VHR patients using classification and regression tree (CART) analysis.

METHODS: We performed a retrospective analysis of all patients in a 28-hospital US healthcare system in 2018. ICD-10 codes were used to define the ASCVD …

Syncope Or Seizure?, Joseph Heron, Kevin Dwyer

Rowan-Virtua Research Day

Syncope is a common complaint in the emergency departments, accounting for 1-2% of visits, and can approach admission rates of a staggering 85%. The causes and conditions can be numerous, ranging from benign to life threatening. A good background history can go a long way in determining the etiology of the patient’s syncope. We describe a case of an elderly male who presented with a reported chief complaint of seizures, another syncope-mimic seen in the emergency department. He had a history of CAD, HTN, AAA, and osteoarthritis but no prior history of cardiac arrhythmia, MI, or structural heart disease. The …

Use Of Point Of Care Ultrasound In The Emergency Department For Diagnosis Of Femoral Pseudoaneurysm, Stephen Janssen, Jeffrey Gardecki, Giovanna Finocchio

Rowan-Virtua Research Day

Iatrogenic pseudoaneurysm after puncture or intervention of the femoral artery is a rare complication of arterial surgical intervention occurring in 0.05-0.50% of diagnostic and therapeutic catheterizations and can present weeks after initial presentation. Today we present a 57-year-old gentleman 3 months status post femoral artery stent who presented with swelling to his right groin. Point of care ultrasound was used to diagnose an actively bleeding pseudoaneurysm with hematoma that ultimately led to repeat stenting. This case shows how point of care ultrasound can expedite diagnosis and intervention and is a useful tool for the emergency physician at initial presentation.

The Application Of Point-Of-Care Ultrasound In Ed Intubations And Airway Access: A Systematic Review, Frank Wheeler, James Espinosa, Alan Lucerna, Jeffrey Gardecki

Rowan-Virtua Research Day

Intubation is an essential procedure performed on a routine basis in the emergency room. Unsuccessful intubations are associated with deleterious outcomes. A systematic review was performed to investigate the accuracy of point of care ultrasound (POCUS) in successful Endotracheal Tube (ET) tube confirmation, utilizing ultrasonography, identification of the cricothyroid membrane utilizing ultrasound, and dynamically during use of ultrasonography in the process of intubation. This review demonstrated high sensitivity and specificity for ultrasound confirmation of ET tube placement, high success rate in ultrasound-guided intubation, and lower than expected accuracy in identifying the cricothyroid membrane. Ultrasonography should be considered for ET tube …

Spontaneous Conus Medullary Infarction In The Absence Of Cardiovascular Risk Factors, Bavica Gummadi, Jaffer Ahmed, Swarna Rajagopalan

Rowan-Virtua Research Day

Spinal cord infarction (SCI) is rare and most often occurs in individuals with predisposing cardiovascular risk factors and traumatic injuries

As there are no distinct diagnostic criteria for SCI, diagnosis is difficult in patients presenting without predisposing factors and is often mistaken for transverse myelitis.

Delay in early diagnosis contributes to the high case fatality rate of SCI.

This case highlights the importance of including SCI in the differential of a patient with acute paraparesis even in the absence of co-existing risk factors.

An Unusual Ed Case: Cardiac Tamponade Presenting As Hiccups, Devleen Baksi, Nicholas Tomasello, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Cardiac tamponade is an emergent life threating condition that depending on cause can quickly progress to death. The rate of accumulation of a pericardial effusion often can determine the clinical severity. Typically, shortness of breath and hypotension manifest; however, in this unusual case, the initial presenting complaint was persistent hiccups.

Case Study Of Pulmonary Embolism With Unusual Chief Complaint, Kajel Patel

Rowan-Virtua Research Day

Pulmonary embolism (PE) is a serious diagnosis that needs to be made in the Emergency department (ED). There are different categories of PE ranging from massive to non-massive/sub-segmental. Regardless of the categorization, the patient will need to be placed on anticoagulation. It is important to catch this diagnosis in the ED so further complications do no arise. Here is a case from the ED with a patient coming in with the chief complaint of acute right lower quadrant abdominal pain and was diagnosed with a pulmonary embolism.

C25: The “Spot Sign”: A Predictor Of Hematoma Expansion, Mckenzie Merritt

Annual Research Symposium

No abstract provided.

Management Of Refractory Ventricular Fibrillation With Double Sequential Defibrillation, Kaitlyn A. Brown

Capstone Showcase

Patients experiencing cardiac arrest are treated according to ACLS protocols, however current protocols lack recommendations for the treatment of refractory Ventricular Fibrillation which persists after more than 3 cycles of CPR and defibrillation. One potential intervention for these cases that is being researched is the use of simultaneous or sequential activation of two defibrillators. This literature review analyzed the results of several studies to determine if double sequential defibrillation (DSD) is a viable treatment to achieve return of spontaneous circulation (ROSC) and improved patient survival. The results of the studies were mixed with some showing positive outcomes, and others showing …

Transfer Of Patients With St Elevation Myocardial Infarction For Primary Percutaneous Coronary Intervention During Ordinary & Pandemic Times Position Statement Of The Saudi Arabian Cardiac Intervention Society, Shukri M. Al Saif, Owayed Al Shammeri, Abdullah Alkhushail, Ramzi Almohammadi, Mohamed Kurdi

Journal of the Saudi Heart Association

Primary percutaneous coronary intervention is the most effective therapy in the management of acute ST Elevation Myocardial Infarction. Evidence recommends keeping the period from symptom onset to reperfusion to a minimum in order to preserve left ventricular function, improve outcome, and reduce mortality. The position statement describes the recommendations of the the Saudi Arabian Cardiac Intervention Society for optimal conditions and timing for the acute management of patients presenting with ST Elevation Myocardial Infarction during ordinary and pandemic times.

Nurse-Initiated Protocols For Chest Pain In The Emergency Department, Matthew Hodges

Student Scholarly Projects

Practice Problem: Emergency department crowding inhibits the ability to provide safe patient care to chest pain patients and negatively impact patient outcomes. A Veteran Affairs emergency department has identified a similar concern and implemented a nurse-initiated protocol to decrease the length of stay and improve patient outcomes.

PICOT: This evidence-based practice (EBP) project was guided by the following PICOT question: In the emergency department (ED), how does a nurse-initiated protocol (NIP) for chest pain (CP) patients compared to no protocol use influence length of stay (LOS) in the ED over 8 weeks?

Evidence: The reviewed literature supported the evidence of …

Multi-Community Cardiopulmonary Resuscitation Education By Medical Students, Kenton L Anderson, Kian Niknam, Larry Laufman, Stefanie S Sebok-Syer, Sara Andrabi

Faculty, Staff and Students Publications

Introduction One purpose of the hands-only cardiopulmonary resuscitation (HOCPR) program is to simplify CPR instruction to encourage more bystanders to take action during cardiac arrest. Although the program has been successfully implemented in traditional classroom settings, the utility of large-scale training events has not been well-explored. We hypothesized that CPR knowledge and comfort levels would increase through a large-scale, multi-community HOCPR training event. We also explored what effect this training event had on perceived barriers to bystander-performed CPR. Methods A convenience sample participated in HOCPR training on a single day across 10 Texas cities. A sub-sample completed training questionnaires, including …

Bedside Point Of Care Ultrasound Diagnosing Bilateral Valve Involvement In Infective Endocarditis, Corey Cole, Alfredo Tirado, Jonathan Schwadron

West Florida Division GME Research Day 2020

Endocarditis is a well known complication of intravenous drug abuse which classically affects the tricuspid valve. It is usually diagnosed by formal echocardiogram and positive blood cultures. Vegetations involving both the mitral and tricuspid valves are rare, occurring in less than 5% of all cases of infective endocarditis. 1 Here we report a case of a patient with vegetations on both valves which was discovered by point of care ultrasound.

End The Glow!, Roli Kushwaha, Anthony Furiato, Justin Mcnamee

West Florida Division GME Research Day 2020

Aortic dissection (AD) is part of a group of acute aortic syndromes consisting of intramural aortic hematoma, penetrating aortic ulcer, and aortic rupture. On its own, the incidence is ~3 to 8 cases per 100,000 per year, and up to 25% of cases are missed. The in-hospital mortality when treated is 27%, and with a 2% increase in mortality/hour. Imaging modalities like CT angiography, TEE, and MRA have made improved diagnosis of the disease, but are costly, potentially harmful, time consuming, and require patient stability when in use (1). The key question we have as emergency department providers is if …

Evolving De Winter Presentation Of Acute Myocardial Infarction, Caroline Shepherd, Anthony Furiato

West Florida Division GME Research Day 2020

de Winter ECG pattern first detailed in 2008 in a case series Diagnostic criteria

• Tall, prominent, symmetric T waves in the precordial leads
• Upsloping ST segment depression >1mm at the J-point in the precordial leads
• Absence of ST elevation in the precordial leads
• ST segment elevation (0.5mm-1mm) in aVR

Strongly correlated with acute LAD occlusion

Hispanics Have Higher Grade Intracerebral Hemorrhage Compared To Non-Hispanics, Jessica Houck Do, Tej Stead, Paul Banerjee, Latha Ganti Md

Emergency Medicine

No abstract provided.

Knowledge Gain Of The Non-Vascular Surgeons After Attending A Course On Traumatic Vascular Emergencies, Zia Ur Rehman, Muhammad Asad Moosa, Qamar Riaz

Department of Surgery Docs

Objective: To measure the effectiveness of the workshop in enhancing the knowledge and skills of the non-vascular surgeons in dealing with traumatic vascular emergencies.
Methodology: It was a Quasi-experimental pre-post design study conducted at Section of Vascular Surgery, Aga Khan University Hospital, Karachi (Pakistan) in February 2019. One-day workshop was conducted to enhance the knowledge and operative skills of the non-vascular surgeons in managing traumatic vascular emergencies. A written test and course evaluation survey were used to evaluate the effectiveness of the course in achieving the desired objectives.
Results: Total of 21 participants attended the workshop with mean age of …

Process Factors Affecting Reperfusion Time In Patients Presenting With St-Segment Elevation Myocardial Infarction (Stemi), Richard R. Wall

Theses and Dissertations

Abstract PROCESS FACTORS AFFECTING REPERFUSION TIME IN PATIENTS

PRESENTING WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI) By Richard R. Wall MSRS, RT(R)(CT)(CI), RCIS

A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University.

Virginia Commonwealth University, 2020.

Dissertation Chair: Jeffrey S. Legg Ph.D. Associate Professor and Chair, Department of Radiation Sciences

An ST-segment myocardial infarction (STEMI) occurs when the blood flow to the myocardium is suddenly and completely blocked causing the myocardium to become ischemic. A STEMI is a life-threatening condition that necessitates emergent medical treatment. Research has shown that longer …

Results Of A Phase 1 Multicentre Investigation Of Dexmedetomidine Bolus And Infusion In Corrective Infant Cardiac Surgery, Athena F Zuppa, Susan C Nicolson, Nicole S Wilder, Juan C Ibla, Erin A Gottlieb, Kristin M Burns, Mario Stylianou, Felicia Trachtenberg, Hua Ni, Tera H Skeen, Dean B Andropoulos

Faculty, Staff and Students Publications

BACKGROUND: Dexmedetomidine (DEX) is increasingly used intraoperatively in infants undergoing cardiac surgery. This phase 1 multicentre study sought to: (i) determine the safety of DEX for cardiac surgery with cardiopulmonary bypass; (ii) determine the pharmacokinetics (PK) of DEX; (iii) create a PK model and dosing for steady-state DEX plasma levels; and (iv) validate the PK model and dosing.

METHODS: We included 122 neonates and infants (0-180 days) with D-transposition of the great arteries, ventricular septal defect, or tetralogy of Fallot. Dose escalation was used to generate NONMEM® PK modelling, and then validation was performed to achieve low (200-300 pg ml …

Listen To Your Heart, Or At Least Theirs: Maintaining A High Index Of Suspicion For Infective Endocarditis, Mollie Powell Do, Mahesh Setty Md

Emergency Medicine

After an endothelial injury, a fibrin and platelet cap forms. This cap is typically sterile but in times of infection can become colonized by microbes leading to a vegetation. When this occurs on the endothelium of the heart, it is termed infective endocarditis (IE). IE is a difficult diagnosis to make in the ED. The symptoms are vague. Classic exam findings are often absent, murmur auscultation can be challenging and there is not a single diagnostic test. A delayed or missed diagnosis can be fatal; therefore, it is essential that ED physicians maintain a high index of suspicion in high …

The Effectiveness Of Interventions And Bundles For Central Line-Associated Bloodstream Infections In The Neonatal Intensive Care Unit, Mohamad Alhamwi

Honors Undergraduate Theses

Introduction: Central Line-Associated Bloodstream Infections (CLABSIs) are a major cause of increased mortality, morbidity and healthcare costs in neonatal intensive care units (NICUs) patients. Despite CDC's efforts to reduce infection rates, patients often suffer consequences. The objective of this study is to perform a systematic review of strategies utilized in the neonatal population and evaluate them with the current CDC's guidelines to assess the effectiveness of bundles in preventing CLABSI in NICUs.

Methods: A systematic literature search was conducted using CINAHL Plus with Text, Cochrane Database of Systematic Reviews and MEDLINE from January 2008 up to 2018. There were multiple …

Treatment Of Hypertensive Emergencies, Wilbert S. Aronow

NYMC Faculty Publications

No abstract provided.