Emergency Medicine Commons^™

Woman With A Lump Under Her Tongue, Rachel Sealby, Steven Goodfriend, Martin Wegman

South Atlantic Division GME Research Day 2024

No abstract provided.

Impact Of Receiving Hospital On Out‐Of‐Hospital Cardiac Arrest Outcome: Racial And Ethnic Disparities In Texas, Ryan Huebinger, Marina Del Rios, Benjamin S Abella, Bryan Mcnally, Carrie Bakunas, Richard Witkov, Micah Panczyk, Eric Boerwinkle, Bentley Bobrow

Faculty, Staff and Student Publications

Background Factors associated with out-of-hospital cardiac arrest (OHCA) outcome disparities remain poorly understood. We evaluated the role of receiving hospital on OHCA outcome disparities. Methods and Results We studied people with OHCA who survived to hospital admission from TX-CARES (Texas Cardiac Arrest Registry to Enhance Survival), 2014 to 2021. Using census data, we stratified OHCAs into majority (>50%) strata: non-Hispanic White race and ethnicity, non-Hispanic Black race and ethnicity, and Hispanic or Latino ethnicity. We stratified hospitals into performance quartiles based on the primary outcome, survival with good neurologic outcome. We evaluated the association between race and ethnicity and …

From Covid-19 To Long Covid; The Forms Of The Neurological Manifestations, Sana Ahuja, Sufian Zaheer

Journal of Mind and Medical Sciences

Ever since the SARS-CoV-2 infection was declared a global pandemic in 2020, numerous multisystemic manifestations have been discovered. The COVID-19 is known to cause a wide spectrum of neurological symptoms like fatigue, headache, brain fog, stroke, smell and taste disorders, encephalopathy and neurodegenerative disorders. The neurological manifestations are more prevalent in the post-COVID syndrome or long COVID. The National Institute for Health and Care Excellence and WHO defined Ongoing Symptomatic COVID as 4-12 weeks post infection and post COVID-19 syndrome as persistence of symptoms beyond 12 weeks. So far there are limited data available regarding the pathophysiology of neurological symptoms …

A Previously Healthy Infant With Lemierre Syndrome In The Emergency Department: Case Report, Adeola Adekunbi Kosoko, Omoyeni O Clement

Faculty, Staff and Student Publications

INTRODUCTION: Lemierre syndrome (LS) is a rare condition with a high mortality risk. It is well described in older children and young adults involving bacteremia, thrombophlebitis, and metastatic abscess commonly due to Fusobacterium infections. Young, pre-verbal children are also susceptible to LS; thus, careful attention must be given to their pattern of symptoms and history to identify this condition in the emergency department (ED).

CASE REPORT: A 12-month-old previously healthy boy with a recent diagnosis of acute otitis media and viral illness presented to the ED with a complaint of fever. Additional symptoms developed at the head and neck and …

Abatacept, Cenicriviroc, Or Infliximab For Treatment Of Adults Hospitalized With Covid-19 Pneumonia: A Randomized Clinical Trial, Jane A O'Halloran, Emily R Ko, Kevin J Anstrom, Eyal Kedar, Matthew W Mccarthy, Reynold A Panettieri, Martin Maillo, Patricia Segura Nunez, Anne M Lachiewicz, Cynthia Gonzalez, P Brian Smith, Sabina Mendivil-Tuchia De Tai, Akram Khan, Alfredo J Mena Lora, Matthias Salathe, Gerardo Capo, Daniel Rodríguez Gonzalez, Thomas F Patterson, Christopher Palma, Horacio Ariza, Maria Patelli Lima, John Blamoun, Esteban C Nannini, Eduardo Sprinz, Analia Mykietiuk, Radica Alicic, Adriana M Rauseo, Cameron R Wolfe, Britta Witting, Jennifer P Wang, Luis Parra-Rodriguez, Tatyana Der, Kate Willsey, Jun Wen, Adam Silverstein, Sean M O'Brien, Hussein R Al-Khalidi, Michael A Maldonado, Richard Melsheimer, William G Ferguson, Steven E Mcnulty, Pearl Zakroysky, Susan Halabi, Daniel K Benjamin, Sandra Butler, Jane C Atkinson, Stacey J Adam, Soju Chang, Lisa Lavange, Michael Proschan, Samuel A Bozzette, William G Powderly, Activ-1 Im Study Group Members

Faculty, Staff and Student Publications

IMPORTANCE: Immune dysregulation contributes to poorer outcomes in COVID-19.

OBJECTIVE: To investigate whether abatacept, cenicriviroc, or infliximab provides benefit when added to standard care for COVID-19 pneumonia.

DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-masked, placebo-controlled clinical trial using a master protocol to investigate immunomodulators added to standard care for treatment of participants hospitalized with COVID-19 pneumonia. The results of 3 substudies are reported from 95 hospitals at 85 clinical research sites in the US and Latin America. Hospitalized patients 18 years or older with confirmed SARS-CoV-2 infection within 14 days and evidence of pulmonary involvement underwent randomization between October 2020 and …

Coronary Artery Disease As An Independent Predictor Of Cardiovascular Mortality In Covid-19 Patients, Hywel Soney, Nathan Deron, Lucas Wang, Lawrence Hoang, Mujahed Abualfoul, Yi Zhao, Kristopher Aten, Victor Canela, Sri Prathivada, Michael Vu, Manavjot Sidhu

Faculty, Staff and Student Publications

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with increased risk of cardiovascular mortality. However, little is known about the combined effect of coronary artery disease (CAD) and COVID-19 on mortality. We aimed to investigate the incidence of cardiovascular and all-cause mortality in COVID-19 patients with CAD.

METHODS: This multicenter retrospective study identified 3,336 COVID-19 patients admitted between March and December 2020. Data points were manually reviewed in the patients' electronic health records. Multivariate logistic regression was used to assess whether CAD and its subtypes were associated with mortality.

RESULTS: This study shows that CAD was not an independent predictor of …

Mixed Beri’S: High Output Heart Failure From Severe Anemia And Thiamine Deficiency, Rohan Umrani, Hiral Amin, Ashley Pinckney, Charles Yang, Daniel Tran

Rowan-Virtua Research Day

Background: Severe anemia and thiamine deficiency can independently result in high output heart failure (HOHF) through different mechanisms. Data on the threshold and timeframe at which these etiologies may precipitate HOHF is unclear.

Case: A 63-year-old male with alcohol use disorder consuming 18 drinks/week presented with progressive shortness of breath and lower extremity edema for a few months. Physical exam revealed tachycardia, anasarca, jugular venous distension, Lancisi’s sign, and a midsystolic murmur. Echocardiogram demonstrated EF of 30-35%, dilated left ventricle, and cardiac index of 4.2L/min/m2.

Decision-Making: Heart failure can independently precipitate anemia while severe alcoholism can induce myelosuppression and promote …

Management And Considerations In The Usage Of Txa In Hemorrhagic Trauma Patients, Matthew Petterson, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Tranexamic acid is a synthetic reversible competitive inhibitor that exerts its action on plasminogen, preventing plasmin formation and deterring fibrinolysis.1 Current FDA-approved indications of TXA include heavy menstrual bleeding and short-term blood loss prevention in patients with hemophilia following tooth extraction.1 TXA has more recently been utilized in the management of massive hemorrhagic trauma patients despite this being an off-label use. While TXA has shown promise as a hemostatic agent for this patient population, considerations in the pre-hospital and hospital settings must be examined for its integration into massive hemorrhage protocols.

Case Report: Epinephrine-Containing Topical Anesthetic Gel Inducing Systemic Epinephrine Toxicity, Md Fateha, Philip Willsie

Rowan-Virtua Research Day

Systemic epinephrine toxicity is a rare complication following inadvertent or excessively large or rapid subcutaneous, intramuscular or intravenous administration. Signs and symptoms of epinephrine toxicity include rapid onset of transient agitation, hypertension, tachycardia, lactic acidosis, and dysrhythmias with potentially fatal consequences. In this case report, we present a 33-year-old female who experienced epinephrine toxicity following the use of a topical anesthetic cream containing lidocaine and epinephrine. The patient had multiple applications to her chest before and during tattoo placement which led to tachycardia, elevated blood pressure, headache, chest pain, nausea, vomiting, and anxiety. The patient was brought into the ED …

Purple Urine Bag Syndrome (Pubs) In A Patient With A Chronic Indwelling Foley, Kelsey Murray, Kishan B. Patel

Rowan-Virtua Research Day

Purple urine bag syndrome (PUBS) is a rare medical condition characterized by the appearance of purple discoloration in the urine collection bag of patients who use catheters for urinary drainage. PUBS is primarily seen in elderly, female, and institutionalized patients who have chronic indwelling catheters. The discoloration occurs due to the presence of certain bacteria that produce pigments, which react with the plastic materials of the catheter and urine collection bag, leading to the formation of a purple color. In addition to the aesthetic concerns, PUBS may also indicate an underlying urinary tract infection or other medical conditions that require …

Obstructive Hydrocephalus Caused By A Colloid Cyst Presenting As A Transient Ischemic Attack (Tia), Muhammad Nadeem

Rowan-Virtua Research Day

Colloid cysts are benign growths commonly found in the third ventricle or at the Foramen of Monroe. They are composed of epithelial lining filled with gelatinous material that contain cholesterol, mucin, old blood and ions. Most colloid cysts are asymptomatic but can present with a variety of symptoms that range from headaches, diplopia, memory problems, and vertigo. They can also present as an obstructive hydrocephalus with the classic “Wet, wacky and wobbly” triad. Rarely colloid cysts have been reported to cause sudden death. They can present to the ED with any spectrum of these symptoms.

An Unusual Ed Case: Spontaneous Necrotizing Fasciitis Presenting As Hypoxic Pneumonia, Chetna Thawani, Kishan Patel

Rowan-Virtua Research Day

We present a case of necrotizing fasciitis initially presenting as septic hypoxic pneumonia, and discuss imaging modalities and diagnostic evaluation. Necrotizing soft tissue infection (NSTI) is a rapidly progressive surgical emergency with a mortality rate of 30%. In approximately 80% of cases, it is introduced through a break in the skin. It can also occur after any invasive procedure or surgery. It is most commonly associated with skin flora including staph and strep, though polymicrobial infections are most common. It usually presents with signs of systemic infection, including fever, chills, sepsis, altered mental status - and signs of cutaneous involvement …

Importance Of Serial Ekgs In The Emergency Room Setting, Swet Patel, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Chest pain is one of the most common chief complaints that presents to the emergency department. More than 8 million patients with chest related complaints present each year with about 10% of all ED visits comprise of cardiovascular emergencies. Immediate evaluation is the standard of care to differentiate between life threatening conditions and non-life threatening ones with the use of 12-lead electrocardiograph (EKG) and bedside monitors. The 12 lead EKG remains gold standard for initial screening and evaluating patients with chest pain and angina equivalents. The test is fairly inexpensive and noninvasive with providing vital information about cardiac rhythm. The …

Brash Syndrome Case Report And Brief Review, Kelly Schuitema

Rowan-Virtua Research Day

BRASH syndrome is an acronym that stands for bradycardia, renal failure, AV node blocker, shock and hyperkalemia. The syndrome is precipitated by synergism from AV nodal blocking agents and hyperkalemia. The combination of the AV nodal blockade and renal failure leads to a cycle of severe bradycardia and hyperkalemia. We will discuss a case of BRASH syndrome with a 68 year old female who presented with generalized weakness and was found to be hypotensive, bradycardia, in acute renal failure with hyperkalemia likely related to metoprolol and amlodipine use.

Release The Kratom: Post-Acute Withdrawal Syndrome In A 70 Year Old Male, Nardin El-Shammaa, Kyle Street, Narsimha Pinninti

Rowan-Virtua Research Day

Centuries in Eastern medicine.. Kratom has been commonly used for chronic pain and opiate withdrawal symptoms with first reported cases in the United States in the early 2000s. It is a plant that consists of psychoactive alkaloids that target opioid receptors with different affinity. Effects from Kratom are dose-dependent, at lower doses, it acts as a stimulant, while at higher doses produces analgesia and euphoria. Although Kratom is legal and easily accessible over the counter, there have been increasing reports of potential for addiction and toxicity. Cessation of Kratom can result in withdrawal symptoms similar to opiate withdrawal. Here we …

Development Of Schizophrenia In A Genetically Predisposed Individual Following Covid-19, Sung Kang, Jonathan Yuh, Timothy Wong

Rowan-Virtua Research Day

We present a patient who is a 56-year-old female with a psychiatric history of anxiety disorder and a medical history of hypercholesterolemia and hyperthyroidism, who was admitted to the hospital after a witnessed seizure at an inpatient psychiatric facility. This patient’s family history is significant for her mother experiencing unspecified psychotic disorder that required psychiatric hospitalization. Our patient was first admitted to the psychiatric hospital after exhibiting worsening paranoid delusions and hallucinations that began several months prior. The patient had reportedly begun locking herself in the restroom and screaming “get out, they’re spying on me”, referring to her next-door neighbors …

Case Report: Anaphylactic Reaction To Magnesium Sulfate, Nicholas Coan, Kelly Schiers, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 65-year-old female who prior to being discharged from the hospital developed an anaphylactic reaction after receiving an intravenous magnesium sulfate infusion. After extensive literature review, there are few documented hypersensitivity reactions documented. This case report is to highlight a known human response, anaphylaxis, but in response to the repletion of an essential electrolyte to human life, magnesium.

Handheld Bedside Pocus In The Evaluation Of Neck Swelling: A Case Of Ludwig's Angina, Alex Gechlik, Frank Wheeler, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Ludwig's angina is a rare and life threatening cellulitic infection, first described by German physician, Wilhelm Frederick Von Ludwig in 1836, as a gangrenous infection of the soft tissue floor of the mouth and neck. The potential to spread rapidly to contiguous tissues surrounding the upper airways, notably the glottis, resulted in Ludwig's angina carrying a high mortality rate near 50% in the pre- antibiotic era. It necessitates rapid detection and management to assure respiratory compromise does not occur. This case study is novel as it illustrates handheld bedside POCUS utilization in diagnosing Ludwig’s Angina.

Case Report And Review: Hawthorne Root Toxicity, James Espinosa, Darren Finn, Alan Lucerna

Rowan-Virtua Research Day

Here we present the case of a patient who purchased a hawthorn root product, Raiz de Tejocote, for weight loss purposes. The side effect profile seen, including a positive digoxin level, are consistent with hawthorn root. This case reinforces the importance of asking a patient about all medications, including over the internet medications.

Case Report: Ocular Capsaicin Toxicity With Chemosis From Jalapeño Peppers, Duwayne Campbell, James Espinosa, Eric Maddock, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

A 42 year old female presented to an Emergency Department (ED) with the abrupt onset of left eye pain, tearing and eye redness of a one hour duration. Her symptoms were due to ocular toxicity from contact exposure to capsicum, through preparation of Jalapeño peppers.

Infective Endocarditis Secondary To Needle Embolization To The Heart, Tony Elias, David Barsoum, Robert Malak, Veyola Rezkalla, Maziyar Daneshvar, Howard Weinberg, Rafail Beshai

Rowan-Virtua Research Day

Needle embolisms in the heart are very rare, even though the number of intravenous drug users (IVDUs) has increased over the past 10 years.Due to varied symptomology-chest pain, dyspnoea, fever, or asymptomatic, this remains a complex and likely underdiagnosed condition. We describe a 31-year-old female with past medical history of IV drug use who presented to the emergency room with heart palpitations and described it as her “heart feels funny” and shortness of breath. She acknowledged intravenous (IV) heroin use and stated that the last time to use IV drugs was 2 days before coming to the hospital.

To our …

Case Study: Posterior Reversible Encephalopathy Syndrome (Pres) In A Stroke Patient With Seizures, Akhmad Ernazarov, Shikhar Manchanda, Yvette Wang

Rowan-Virtua Research Day

Posterior Reversible Encephalopathy Syndrome (PRES) is a condition in which patients present with visual disturbances, headaches, seizures, and impaired consciousness. It can affect a wide variety of patients ranging from infants to elderly, but young and middle aged adults are most commonly affected; females are more likely to be affected by PRES than males. Risk factors such as hypertension, pre-eclampsia/eclampsia, renal failure, cytotoxic conditions and autoimmune conditions predispose patients to PRES. In this unique case, a 63 female patient was admitted to Jefferson Washington Hospital exhibiting classic stroke like symptoms. Patient also began seizing in the ED which was unusual …

Chronic Headache Leading To The Diagnosis Of Empty Sella, Melissa Itidiare Locke, Rachel Burke

Rowan-Virtua Research Day

Headaches are one of the most common chief complaints presenting to the Emergency Department. The differential is broad. The workup is tailored to the patient’s history. Here we present the case of a young female who developed headaches over the past year. After numerous imaging studies of her brain, the most recent revealed an Empty Sella diagnosis.

Case Report: Use Of Bedside Handheld Ultrasound To Diagnose Finger Dislocation, Frank Wheeler, Philip Carhart, James Espinosa, Alan Lucerna, Henry Schuitema

Rowan-Virtua Research Day

Here we present the case of a 37-year-old male with a finger injury in which finger dislocation was suspected clinically. A bedside pocket ultrasound was performed using a water submersion technique, which identified a posterior dislocated right 2nd digit at the PIP joint. This finding was confirmed with an x-ray. This case report demonstrates that ultrasonography can be utilized to correctly identify finger dislocation. Although larger studies need to be performed to validate the accuracy of this imaging technique, the implications may improve care of the patient. It would also be particularly beneficial for this technique to be applied to …

Case Report And Review: Promethazine ("Purple Drank") Abuse, Riya Tandra, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

A 23 year old female was brought to the Emergency Department by EMS for confusion and aggressive behavior. The friends told EMS that the patient had been ingesting "purple drank" and that she had told her friends that she made the concoction with promethazine and opiate cough syrup with some vodka added. She mixed it in a carbonated soda. “Purple Drank” or “Lean” is a combination of codeine promethazine hydrochloride and soda or alcohol that has frequently been misused since the 1990s. This paper aims to highlight the recent resurgence of promethazine abuse occurring in the United States as well …

End Of Life Symptom Management In The Emergency Department, Alice Chang, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

The Emergency Department is at times the only place patients can turn to for symptom relief. In an aging population, this means that more patients are presenting to the ED towards the end of life (EOL). Emergency medicine (EM) prides itself as a specialty that handles disease-directed treatment for a variety of acute conditions. In contrast, palliative care (PC) is focused on improving the quality of life (QOL). It has become essential for EM physicians to care for patients who are not seeking life-sustaining measures, but instead quality of life interventions. Patients with serious illness, even hospice patients, present to …

Ureterocutaneous Fistula In Setting Of Recurrent Gluteal Abscesses: A Case Report, Catherine Alapatt, Young Son, Benjamin Fink, Brian Thomas, Sean Coulson, Shawon Akanda, Jacob Thatcher, Thomas Mueller

Rowan-Virtua Research Day

Ureteral fistulas are a rare occurrence that can arise from iatrogenic trauma, radiation, malignancy, and inflammation. Treatment options of urinary tract fistulas are handled on a case-by-case basis and can necessitate a surgical approach. We present the case of an 85-year-old patient with a ureterocutaneous fistula where conservative management with PCN is a viable alternative to surgical intervention.

Case Report: Carbon Monoxide Poisoning: A Sleuth, Joel Collins Ii, Wayne Tamaska, Anna Barton, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 18 year old male who presented via EMS who was called for an unconscious male in his car diagnosed initially with opioid overdose and later found to have carbon monoxide poisoning. The differential diagnosis of carbon monoxide poisoning is someone broad and non specific, but in general, carbon monoxide poisoning can be initially elusive in diagnosis and requires continued consideration. This remains true especially in this case of an unconscious male with initial responsiveness to naloxone. It is predictable that as with time the preponderance and relative commonality of this condition will decrease with …

When Constipation Becomes Lethal: Septic Shock Induced By Stercoral Colitis In A 77-Year-Old Female, Anna Delancy, Nicholas Tomasello, Joan Wiley, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Stercoral colitis is a form of colitis caused by fecal impaction distending the colon and causing fecaloma formation. Fecalomas lead to pressure necrosis of the colon and eventual perforation. The increased intraluminal pressure from the distention of the colon causes vascular compromise and ischemia. The most common locations of necrosis are in the sigmoid colon and rectum . When progressed to perforation, the mortality rate is as high as 60%. The most common cases of stercoral colitis occur in nursing home patients, mentally impaired patients, or those with chronic constipation. Here we describe an unusual case of stercoral colitis causing …

Brief Review: Iv Fluid Choice In The Emergency Department, Kaywan Saed, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Normal saline and balanced crystalloids, such as lactated Ringer's (LR) and Plasma-Lyte A, are commonly used in the emergency setting for fluid resuscitation. However, there has been growing interest in recent years in whether balanced crystalloids may be superior to normal saline, particularly in critically ill patients.

Normal saline has been the traditional fluid of choice for decades due to its widespread availability, low cost, and presumed safety. However, normal saline has a high chloride concentration (154 mmol/L), which can lead to hyperchloremic metabolic acidosis and other adverse effects, such as renal vasoconstriction and reduced renal blood flow.

In contrast, …