Emergency Medicine Commons^™

Spontaneous Splenic Laceration Presenting As Stable Angina In The Ed, Lea Rowson, James Baird

Rowan-Virtua Research Day

We present a case of a 62-year-old female who presented to the emergency department complaining of classic cardiac chest pain and was ultimately diagnosed with hemoperitoneum due to a splenic laceration sustained during recent colonoscopy. The signs and symptoms between these two diagnoses can be vaguely similar, and a missed diagnosis of either leads to increased morbidity and mortality. To make an appropriate diagnosis, a thorough history and physical examination is imperative. Observation of non-musculoskeletal left shoulder pain in addition to abdominal tenderness should lead the astute clinician down a different path towards diagnosis. Kehr’s sign is present in many …

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.

Case Report: Covid-19 Associated Guillain-Barre Syndrome, Matthew Aharonov, Neelesh Parikh, James Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 72-year-old female who presented to the emergency department with a complaint of generalized weakness. The patient was found to have ascending muscle weakness and subsequently diagnosed with Covid-19 related Guillain-Barre Syndrome. Our patient was negative for Campylobacter jejuni. It is noteworthy that the patient did not have fever, respiratory symptoms or loss of the sensation of taste.

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.

Triad Of Acute Pancreatitis Coexisting With Diabetic Ketoacidosis And Very Severe Hypertriglyceridemia Successfully Resolved With Insulin Therapy Alone, Akash Patel, Monica Patel, Yvette Wang

Rowan-Virtua Research Day

Diabetic ketoacidosis (DKA) is known to cause mild elevations in triglyceride levels.

Severe hypertriglyceridemia (HTG) is a well-known cause of acute pancreatitis; however, in unique cases, DKA has been shown to cause severe HTG leading to the development of acute pancreatitis (AP).

HTG causing AP only accounts for 1-4% of cases of AP

From the few cases in literature that have reported this triad of DKA, HTG, and AP, even fewer have shown to be successfully treated with insulin therapy alone with the severe degree of HTG that we discuss.

In our case, we have treated a triad of DKA, …

Stercoral Colitis Leading To Hypotension And Ivc Syndrome With Respiratory Failure Following Fecal Disimpaction, Kelly Schuitema, Nicholas Tomasello

Rowan-Virtua Research Day

Constipation is an extremely common chief complaint in the emergency department, contributing to approximately 700,000 emergency department visits in 2011. Severe constipation can result in stercoral colitis, which in turn can lead to development of ulceration and colonic perforation leading to fatal peritonitis. As a result, prompt recognition and treatment of this condition with bowel cleansing and fecal disimpaction are often recommended. Here, we will discuss a case of a 62-year-old male with a history of schizoaffective disorder who came into the Emergency Department (ED) hypotensive with stercoral colitis secondary to severe constipation. Following bedside fecal disimpaction, the patient developed …

Case Report: The Value Of Vigilance And Iterative Evaluations With An Uncooperative Patient In The Emergency Department, Duwayne Campbell

Rowan-Virtua Research Day

Discussion

A Flexible and Vigilant Approach: The initial presenting information from EMS could have led to anchoring bias. A flexible approach led to new information, which led to interative testing.

Iterative physical examination. There are cases, as seen in this case report, where the physical examination was unreliable or even impossible. Iterative evaluations ultimately led to appropriate imaging and accurate diagnosis.

Iterative testing: In the case presented, the radiologist reported a finding as being present on a prior CXR; however, given the patient’s clinical presentation, further imaging studies were necessary.

From Left Arm Numbness To Incidental Pituitary Macroadenoma, Melissa Itidiare Locke

Rowan-Virtua Research Day

Pituitary adenomas are the most common tumors in the sella turcica. The symptoms of vision loss or change is due to the anatomical location of the pituitary tumor beneath the optic nerve. (2) As the tumor grows in size it can compress the optic nerve and vision changes will occur. Our case demonstrates a 40 year old male who had one brief 1 time episode of blurry vison and dull intermittent headaches that was not debilitating in nature. A discovery of pituitary adenoma prior to onset of symptoms of constant vision changes or elevated hormones are crucial to a more …

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.

Assigning Level Of Care In Blunt Chest Trauma Patients: Applying Objective Scoring Systems, Alyssa Imperatore, Kaitlyn Oldewurtel, James Eakins

Rowan-Virtua Research Day

25% of all traumatic deaths are related to blunt chest trauma and another 50% have in-hospital morbidity and mortality. Recognizing patients with high risk of mortality is just as important as recognizing the immediate severely injured patients. Atlanticare Regional Trauma Center developed a scoring system in an attempt to properly assign these patients to an appropriate level of care. The system was developed based on a literature review but has not yet been studied to review its effectiveness in improving outcomes in chest trauma patients. Therefore, the scoring system is used as a guideline and not an official document in …

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.

Kidney Rupture: An Unusual Cause Of Abdominal Pain, Flank Pain And Hematuria In A 72-Year-Old Female, Monica Diep, Neelesh Parikh

Rowan-Virtua Research Day

Flank pain, abdominal pain and hematuria are common complaints in emergency medicine. We describe the case of a 72-year-old female who presented to the emergency department for worsening left lower quadrant abdominal pain and left flank pain associated with new-onset hematuria. The patient reports the pain started immediately after she accidentally tripped on a rock while trying to avoid a mailman in an attempt to socially distance due to the COVID-19 pandemic, which resulted in a forceful twist of her body and catching herself with her hands without any direct impact to her body. The patient reports the pain gradually …

Omental Infarction: A Rare Cause Of Abdominal Pain, Eric Doane, Emily Nguyen

Rowan-Virtua Research Day

Omental infarction is a rare cause of acute abdomen pain first described by Eitel in 1899 and has been described in the literature with total numbers ranging from 250-400 worldwide with many coming from individual case reports. Risk factors for developing omental infarction are thought to be obesity, trauma, intense exercise or secondary to torsion from adhesions. Historically, the diagnosis of omental infarction was made incidentally in the operating room for patients with an acute abdomen with a different suspected diagnosis. Most often being appendicitis with associated right lower quadrant abdominal pain and smaller subset from suspected diverticulitis and cholecystitis …

An Evaluation Of The Use Of Tranexamic Acid In The Treatment Of Bradykinin-Mediated Angioedema In The Emergency Department, Sarah Yb Kim, Carol Keller

Providence Pharmacy PGY1 Program at Providence Milwaukie and Providence Newberg Medical Centers 2021

Background

Bradykinin mediated angioedema is an overarching term that includes idiopathic angioedema, angiotensin converting enzyme inhibitor (ACEi) induced angioedema and hereditary angioedema (HAE). •This is an emergent condition that must be treated with the utmost urgency due to the fatal outcomes associated with the rapid constriction of the throat. •Bradykinin mediated angioedema is treated differently from histamine associated angioedema due to its resistance to corticosteroids and antihistamines. •HAE and ACEi induced angioedema are treated similarly but there is a lack of unanimity in the first line pharmacologic treatment. •Current treatment options include fresh frozen plasma, bradykinin-2 receptor antagonists, plasma-kallikrein inhibitors …

Medication And Pharmacy-Related Outcomes As Part Of The Seniors At Risk For Falls After Emergency Room Visit (Safer) Project, Hyesoo Chae, Sharon Leigh, Colleen M Casey

Providence Pharmacy PGY1 Program at Providence Portland and Providence St. Vincent Medical Centers 2021

Background

The United States is comprised of an aging population; adults over the age of 85 are the fastest-growing age group in the United States and will reach approximately 9 million in 2030.1 25% of patients ≥ 65 years old in the United States report falling each year.1 There are over 3 million emergency department visits related to falls in the United States, totaling approximately 50 billion dollars in total medical expenditures.2 Falls are a major threat for older adults as they can lead to increased risk of further injury, loss of independence, decreased mobility, and premature death.1,2 Despite numerous …

Antibiotic Durations For Skin And Soft Tissue Infections In Pediatric Urgent Care Clinics, Megan Hamner, Amanda Nedved, Holly Austin, Donna Wyly, Alaina N. Burns, Diana King, Brian R. Lee, Rana El Feghaly

Posters

Background: Skin and soft tissue infections (SSTIs) are the second most common diagnosis leading to pediatric antibiotic prescriptions in the outpatient setting after respiratory diagnoses. However, most antibiotic stewardship programs have mainly focused on the latter. Children seen in the ambulatory setting for SSTIs often receive >7 days of antibiotics, although current society guidelines recommend 5-7 days for most diagnoses.


Objective: To determine the baseline percentage of patients receiving antibiotic prescriptions for >7 days for SSTIs in urgent care clinics (UCC)s of a pediatric health system and to evaluate factors that influence providers towards longer durations.


Design/Methods: We built a …

Evaluation Of The Hypothesis That Viral Meningitis Is A Mimic Of Abusive Head Trauma, Danielle Horton, Tanya Burrell, James Anderst, Lyndsey Hultman, Mary Moffatt, Henry T. Puls, Rangaraj Selvarangan

Posters

Background: Viral meningitis (VM) has been proposed as an alternative cause of subdural hemorrhage (SDH) in young children diagnosed with abusive head trauma (AHT). It has been proposed that VM may mimic symptoms and clinical features of AHT, resulting in an incorrect diagnosis of abuse.


Objective: We aim to evaluate the hypothesis that VM is a mimic of AHT by comparing the history of present illness (HPI) and initial clinical presentation of young children with proven VM to those with subdural hemorrhage and concomitant suspicious injuries (SDH + CSIs) and to those with SDH and no CSIs (SDH only). We …

Simulation Based Clinical Systems Testing Of A Pediatric Ed To Improve Staff And Process Readiness For Pediatric Hypoglycemia, Kevin Meilak Md, Christopher S. Kennedy

Posters

Background: Hypoglycemia is the most common metabolic disorder in children in pediatric emergency department (ED) settings 1. Children may present with nonspecific symptoms, or asymptomatically2. So identification/treatment is very challenging. Delayed recognition and under treatment can lead to poor patient outcomes including seizure, coma, and death. Simulation-based clinical systems tests (SbCSTs) are useful to detect gaps/latent safety threats (LSTs) in system design.3-5


Objective: Our aim was to use SbCSTs combined with rapid cycle training to test system function for ED treatment of hypoglycemia.3-5. The research questions were in 2 frames: 1. Can SbCSTs identify gaps/LSTs and recommendations for improvement and …

Health Disparities In Black, Latinx, And Native Populations Compared To Caucasians: A Retrospective Descriptive-Analysis Of Care Focused On Hypertensive Emergency, Non-St Segment Elevation Myocardial Infarction (Nstemi), And Cerebrovascular Accident (Cva)., Jonathan Aguilar Roa, Evon Anukam

Providence Pharmacy PGY1 Program at Providence Portland and Providence St. Vincent Medical Centers 2021

Background

• Health disparity is a sum of differences in healthcare seen in underserved populations of the United States. 1 • Differences include incidence, prevalence, mortality, burden of disease, and other adverse health conditions • According to ASHP, health disparities continue to be a major public health problem confronting the U.S. health care systems. 2 • Evidence suggests that health disparities can be in part due to differences in the quality of care for different racial and ethnic groups. 2 • All the different disparity factors have been shown to lead to different health outcomes that do not favor Black, …

Evaluation And Implementation Of A New Phenobarbital Protocol For Alcohol Withdrawal Management In The Emergency Department, Sarah J. Kim, Sara Clark, Joshua L. Floyd

Providence Pharmacy PGY1 Program at Providence Portland and Providence St. Vincent Medical Centers 2021

Background

• Alcohol withdrawal syndrome can lead to substantial health care costs and mortality. • Although historically benzodiazepines (BZDs) are considered the mainstay treatment for alcohol withdrawal, some studies have shown that phenobarbital may be the safer and preferred alternative option. • Advantages of phenobarbital are its mechanism of action, more predictable pharmacokinetics, and greater therapeutic index. • A prospective study by Rosenson et al. 2012 found that a single 10 mg/kg IV dose of phenobarbital versus standardized lorazepam protocol resulted in decreased ICU admissions (8% vs. 25%). • A retrospective study by Tidewell et al. 2018 demonstrated shorter hospital …

A Pilot Study Comparing Over And Under Triage Systems At A Center Pursuing Trauma Accreditation, Caitlyn N. Balsay Bs, Mr, Bree A. Harrison Bsn, Rn, Tcrn, Joseph J. Stirparo Md, Michael T. Crowley Md, Nicholas P. Johnson Do, Bryan G. Kane Md, Kathleen E. Kane Md

USF-LVHN SELECT

No abstract provided.

Feasibility Of Implementing A Street Medicine Program To Deliver Naloxone Kits And Associated Education, Gillian A. Beauchamp Md, Lexis Laubach Bs, Hoonani M. Cuadrado Mspas, Pa-C, Seth A. Campbell Pa-C, Lauren Grantz Pharmd, Csp, Paige Roth Lsw, Jennifer E. Macfarlan Mph, Chase Jones Do, Aaron Fedor Do, Marna R. Greenberg Do, Mph, Facep

Department of Emergency Medicine

No abstract provided.

A Pilot Study Comparing Over And Under Triage Systems At A Center Pursuing Trauma Accreditation, Caitlyn N. Balsay Bs, Mr, Bree A. Harrison Bsn, Rn, Tcrn, Joseph J. Stirparo Md, Michael T. Crowley Md, Nicholas P. Johnson Do, Bryan G. Kane Md, Kathleen E. Kane Md

Department of Emergency Medicine

No abstract provided.

Prevalence Of Mycoplasma Genitalium And Macrolide Resistance In Adolescent Females Receiving Care At A Pediatric Hospital, Kayla Barnes, Bishnu Adhikari, Rangaraj Selvarangan, Christopher J. Harrison, Melissa K. Miller

Posters

Background: Mycoplasma genitalium is an established sexually transmitted cause of nongonococcal urethritis in males and macrolide resistance is increasing. The pathogenic role is less well-defined in adolescent females and guidelines recommend M. genitalium testing only be considered in cases of persistent or recurrent cervicitis and pelvic inflammatory disease (PID). We lack understanding of the prevalence and macrolide resistance of M. genitalium in adolescent females.


Objective: To determine the prevalence of M. genitalium and rate of detected macrolide resistance among adolescent females seeking care at a pediatric children’s hospital.


Design/Methods: We collected 200 salvaged urogenital samples (56 urine and 144 vaginal) …

Improving The Rate Of Emergency Department Physician Pre-Procedure Time-Out Documentation For Deep Sedation And Cutaneous Abscess Incision And Drainage, Arjun Sarin, Nikita Sharma, Shobhit Jain

Posters

Background: The pre-procedure time-out, an important safety measure to verify patient identity and accuracy of a planned procedure, and Joint Commission requirement, is not documented consistently by physicians in our emergency department (ED). Deep sedation and cutaneous abscess incision and drainage (I&D) are two high-risk procedures performed in the ED, supporting the use of a time-out in this setting. Between June 2018 and May 2019, a pre-procedure time-out was documented in the physician procedure note of the electronic medical record (EMR) for 75% of deep sedations, and 94% of I&Ds.


Objective: We aimed to improve ED physician pre-procedure time-out documentation …

Teaching Pediatric Procedural Pain And Anxiety Management To Residents: Early Outcomes Of A Newly Developed Curriculum, Jennifer J. Dilts, Brian R. Lee, Shobhit Jain, Ross Newman, Sarah Fouquet, Michael Brancato, Kadriye O. Lewis

Posters

Background: Poorly managed pediatric pain has negative long-term outcomes, including needle phobia, increased pain and anxiety with subsequent procedures, and healthcare avoidance in adulthood. Evidence-based interventions to reduce procedural pain and anxiety are vastly underutilized, and a literature search revealed no specific curriculum to teach residents optimal skills for pain and anxiety management in minor procedures (e.g. venipuncture, laceration repair). Thus, we developed a multimedia-based lecture with PowerPoint, utilizing results from a focus group interview (conducted with 7 pediatric residents, to determine educational content and identify residents’ needs and learning preferences).


Objective: To measure residents’ learning outcomes (knowledge, attitudes, perceived …

Contraception Counseling Of Adolescents Seeking Care In Pediatric Emergency Departments, Cynthia Mollen, Romina Barral, Tara Ketterer, Jungwon Min, Laurel Gabler, Lauren Poole, Amber Adams, Elizabeth Miller, Aletha Akers, Melissa K. Miller

Presentations

Background: Efforts to increase contraceptive use among adolescents are urgently needed. One approach is to use clinical settings that do not routinely provide contraception services, such as the emergency department (ED). Though many are amenable to ED-based contraceptive care, best practices for providing this care are largely unexplored.

Objective: To assess intention to initiate contraception among adolescent females immediately after receiving ED-based contraceptive counseling, and to assess counseling feasibility, contraception initiation and completion of a follow-up visit for contraceptive care.

Design/Methods: Prospective cohort study in two urban pediatric EDs. Using webinar modules and in-person sessions, advanced practice providers (APPs) were …

Lessons From The Pandemic: How A Children’S Hospital Responded To The Challenges Of Covid-19, John Lantos, Paul Kempinski, Laurie Ellison, Jennifer Watts, Angela Myers

Presentations

The COVID-19 pandemic challenged doctors and hospital administrators as did no other event in our lifetimes. Leaders needed to develop a pandemic command structure with the agility to respond to rapidly evolving situations. They had to deal with drastic financial implications, develop new methods of delivering health care, and collaborate regionally. They learned the importance of communication with staff, policy makers, the local medical community, and the public. They had to allocate of scarce resources internally and externally, and balancing rational policy making against irrational fears. For children’s hospitals, some specific challenges included determining our role in a pandemic that …

Using Standardized Scripting To Improve Antibiotic Stewardship In A National Pediatric Urgent Care Collaborative, Amanda Nedved, Melody Fung, Cindy Liu, Rana Hamdy, Amanda Montalbano

Posters

Background: A study using administrative data reported urgent care providers as having the highest rates of inappropriate antibiotic use for upper respiratory illnesses. In a national survey, pediatric urgent care providers reported family expectations as a primary driver for prescribing inappropriate antibiotics. Standardized scripting has been effective at reducing unnecessary antibiotics while increasing family satisfaction.


Objective: To reduce inappropriate prescribing for upper respiratory infections (acute otitis media (AOM), otitis media with effusion (OME), and pharyngitis) in pediatric urgent cares by 20% by December 1, 2020 through use of standardized scripting in Year 2 of a national pediatric urgent care quality …