Emergency Medicine Commons^™

Evaluation Of A Patient With A Severe Systemic Inflammatory Response To Nitrofurantoin, Brigitte Vanle, Timothy Beatty

HCA Healthcare Journal of Medicine

Background

Nitrofurantoin is a prevalent antibiotic used to treat urinary tract infections. Despite nitrofurantoin’s general safety, it can cause serious side effects, including acute pulmonary toxicity, fulminant hepatitis, and severe systemic inflammatory responses, which may mimic conditions such as ischemia and infection. However, reports of acute systemic inflammatory response syndrome after nitrofurantoin ingestion are uncommon in medical literature.

Case Presentation

This case describes a severe systemic inflammatory response syndrome in an 85-year-old woman presenting with hypoxia, altered mental status, and profound leukocytosis after exposure to a single dose of nitrofurantoin.

Conclusion

Herein we report on a patient with suspected bacteremia …

Letter To "Early Do-Not-Attempt Resuscitation Orders And Neurological Outcomes In Older Out-Of-Hospital Cardiac Arrest Patient: A Multicenter Observational Study", Benjamin Tangkamolsuk, Quang La, David F Lo

Rowan-Virtua School of Osteopathic Medicine Departmental Research

We enjoyed reading the article by Kohri et al., titled “Early do‐not‐attempt resuscitation orders and neurological outcomes in older out‐of‐hospital cardiac arrest patients: A multicenter observational study” and would like to offer additional commentary on the article. We hope these perspectives may provide insight into areas that may require further research and improvement.

Epidemiology Of Older Patients Presenting To Irish Emergency Departments: A Subgroup Analysis Of The Egers Dataset, Sean Croughan, Arina Kruis Dr, Kelly Ann Catherine Janssens Dr, Pro Mukerjee Dr, Denys Shchetkovskyy Dr, Áine Mitchell Dr, Mehmet Akif Karamercan Dr, Zerrin Defne Dundar Dr, Anna Slagman Dr, Effie Polyzogopoulou Dr, Sandor Somodi Dr, Andrea Fabbri Dr, Lars Peter Bjornsen Dr, Wilma Beetge, Said Laribi, Rebecca Ann Sealy, Visnja Nesek Adam, Comfort Adedokun Dr, Lucy Gibbons, Pamela O’Brien, Jessica Lynch Dr, Laura Kenny, Conor Deasy Dr, John Ryan Dr, David Menzies Dr, John Cronin Dr, Vijay Narayanan Dr, Nurali Noorani Dr, Waslet Bakhshi Dr, Ahmed Al Rasheed Ahmed Dr, Rosa Mcnamara Dr

Journal of Geriatric Emergency Medicine

Introduction

Within Emergency Medicine, older adults represent a distinct population with unique needs and challenges. There is a scarcity of epidemiologic data on the requirements of Ireland’s older population for, and their utilisation of, emergency care networks. We sought to assess this deficit utilising data from the recently published European Geriatric Emergency Departments Registry Study (EGERS) dataset.

Methodology

A prospective, cohort study of older adult patients (≥65) presenting to Irish Emergency Departments over a 7-day period. The dataset was originally collected as part of the EGERS study. The Irish subpopulation was extracted, analysed in further detail, and compared to the …

A Case Of Isolated Sma Dissection With Failed Initial Conservative Management, Salma Emara, Madison Kropp, Masoud Akbari, Kristin Cook

Rowan-Virtua School of Osteopathic Medicine Departmental Research

Isolated superior mesenteric dissection (ISMAD) is an uncommon condition, often diagnosed incidentally for presentations of acute abdominal pain. Early identification and treatment are crucial as complications such as bowel ischemia or vessel rupture can occur. There remain no established treatment guidelines, making surgical and endovascular indications controversial. A 60-year-old male presented with acute abdominal pain, and was diagnosed with ISMAD via computed tomography imaging. He was initially managed conservatively which progressed to worsening abdominal pain, hypertensive crisis, and hemoperitoneum on follow-up computed tomography angiography (CTA). A mesenteric angiogram revealed a pseudoaneurysm in the superior mesenteric artery (SMA) which was subsequently …

After-Hours, Severity, And Distance Are Associated With Non-Vha Emergency Department Use For Older Veterans: Insights From A Regional Health Information Exchange, Elina Kurkurina, Kimberly M. Judon, Ula Hwang, Kenneth S. Boockvar, Juan Wisnivesky, Matthew R. Augustine

Journal of Geriatric Emergency Medicine

Background: Older adults treated in emergency departments (EDs) are at higher risk for adverse outcomes. Using multiple facilities can worsen this issue through service duplication and poor care transitions. Veterans with dual insurance coverage can access both Veterans Health Administration (VHA) and non-VHA EDs. This study aimed to identify factors associated with non-VHA ED use among veterans.

Methods: We conducted a retrospective observational study of patients aged ≥ 65 who had primary care at the James J Peters VA Medical Center and at least one VHA or non-VHA ED visit between October 2017 and February 2020. Data were collected from …

Implementing The Brief Confusion Assessment Method (Bcam) Delirium Screening Tool In An Emergency Department, Carolina Van Dalen

Master's Projects and Capstones

Problem: Persons with delirium have an elevated risk of falls. Thus, falls and delirium are inextricably linked. Both should be routinely screened for older adults.

Context: A 40-bed Emergency Department (ED) in the East San Francisco Bay area of Northern California and the first site among all acute care hospitals in the organization to implement the Brief Confusion Assessment Method (bCAM) delirium scoring tool within the Electronic Health Record (EHR).

Interventions: An EHR toolkit for delirium screening using bCAM was developed, tested, and implemented in the ED.

Measures: The outcome measure was the percentage of patients with a reported fall …

Delirium Screening Practices For Older Adults In Emergency Departments Across United States: A Scoping Review, Azmat Sidhu, Joy K. Luzingu, Sheneil Agyemang, Arushi M. Chalke, Grace M. Leito, Joseph A. Molina, Zhao Chen, Deborah Jean Mcclelland, Nimit Agarwal, Leah Steckler, Angela Wu

Journal of Geriatric Emergency Medicine

Delirium is commonly missed among older patients in the Emergency Department (ED). Identifying and managing patients with delirium in ED is critical to help improve health outcomes and prevent falls and readmission. There are several validated delirium screening tools but their utilization for assessing delirium in emergency department settings are still under investigation. The overall purpose of this review was to summarize information on current screening practices for delirium among older adults (65 or older) in EDs across United States and to identify current gaps in knowledge and evidence to help inform future research and practice. A comprehensive literature search …

Adipocyte-Derived Small Extracellular Vesicles Exacerbate Diabetic Ischemic Heart Injury By Promoting Oxidative Stress And Mitochondrial-Mediated Cardiomyocyte Apoptosis, Lu Gan, Jianli Zhao, Peng Yao, Theodore A. Christopher, Bernard Lopez, Wayne B. Lau, Walter Koch, Erhe Gao, Xin-Liang Ma, Yajing Wang

Department of Emergency Medicine Faculty Papers

BACKGROUND: Diabetes increases ischemic heart injury via incompletely understood mechanisms. We recently reported that diabetic adipocytes-derived small extracellular vesicles (sEV) exacerbate myocardial reperfusion (MI/R) injury by promoting cardiomyocyte apoptosis. Combining in vitro mechanistic investigation and in vivo proof-concept demonstration, we determined the underlying molecular mechanism responsible for diabetic sEV-induced cardiomyocyte apoptosis after MI/R.

METHODS AND RESULTS: Adult mice were fed a high-fat diet (HFD) for 12 weeks. sEV were isolated from plasma or epididymal adipose tissue. HFD significantly increased the number and size of plasma- and adipocyte-derived sEV. Intramyocardial injection of an equal number of diabetic plasma sEV in nondiabetic …

Prepared To Protect: Improving Cardiac Emergency Response In Youth Club Sports, Melissa Garcia

Nursing | Student Research Posters

Sudden cardiac arrest (SCA) is a medical emergency where the heart unexpectedly stops beating due to an electrical malfunction. A person experiencing a cardiac arrest collapses, loses consciousness, and ceases breathing (American Heart Association, 2022).

Exercise offers numerous benefits to the cardiovascular system and a person’s overall health. However, there are incidents of sports-related cardiac arrest in apparently healthy athletes, including children and young adults. Athletes may be exposed to dehydration, adrenic surges, electrolyte imbalances, acid/base disturbances, and trauma which increases their risk of experiencing a cardiac event (Wasfy et al., 2016).

Sudden cardiac arrest is the leading cause of …

Comprehensive Community Medicine, Alexander Walther

Capstone Projects and Master's Theses

Comprehensive Community Medicine (CCM) is a theoretical framework designed to address the complex needs of individuals with dual diagnoses of mental illness and substance use disorders (SUDs). Dual diagnosis is highly prevalent, particularly among populations experiencing homelessness, and is associated with poorer health outcomes and increased healthcare service utilization. Structural inequities, including a fractured healthcare system, exacerbate the challenges faced by this vulnerable group. Research indicates that effective care for dually diagnosed individuals requires a layered approach addressing clinical, systemic, legal, and housing barriers.

The development of CCM has been informed by interviews with local stakeholders, including County EMS board …

S.T.O.P. Drop It At The Door: Reducing Caregiver Burnout In The Emergency Room, Alexandra Rowen

St. Joseph Hospital, Orange, CA. Evidence Based Practice Conference

No abstract provided.

Improving Confidence Level Of The New Graduate Level Nurse And Nurse Fellows With Managing The Cardiac Arrest Patient, Charles Pfeiffer, Belinda N. Leos

St. Joseph Hospital, Orange, CA. Evidence Based Practice Conference

No abstract provided.

Impact Of Emergency Care Center Specialized Immediate Management Nurse On Quality Metrics, Jo Zarnegar

St. Joseph Hospital, Orange, CA. Evidence Based Practice Conference

No abstract provided.

A Quality Improvement Initiative Using Discharge Education Videos To Improve Communication With Families In A Pediatric Urgent Care, Hannah G. Carron, Gisella Valderrama, Adam A. Vukovic

Patient Experience Journal

Introduction: Effective discharge communication, often given in verbal and written form, during pediatric acute healthcare visits positively impacts caregiver satisfaction and competency in providing at-home care. Institutions are beginning to incorporate evidence-based, and standardized multimedia education to try to further improve these outcomes.

Methods: For this QI initiative, educational videos were created and shown to families prior to discharge from a pediatric urgent care. PDSA cycles focused on development of an electronic medical record (EMR) order to provide video education, a best practice alert regarding this order, and recurrent staff education. The primary outcome measure was the percentage …

Prevalence Of Serious Diagnoses And Disposition Among Older Adults Presenting With A Chief Complaint Of Constipation, A Retrospective Repeated Cross-Sectional Study, Ari B. Friedman, Michael N. Adjei-Poku, Rachel Gonzales, Rachel Kelz, Rachel R. Wu, Anne R. Cappola

Journal of Geriatric Emergency Medicine

A chief complaint of “constipation” in the emergency department (ED) is generally considered low-risk, and potentially suitable for lower acuity care. However, it may also indicate abdominal pain perceived as lower severity by triage staff, despite being relatively high-risk. We hypothesized that ED visits for constipation in older adults would more frequently result in the diagnosis of serious, treatable conditions compared to younger adults. We analyzed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) over an 8-year period (2013-2020). Older adults with constipation were more likely to be non-Hispanic White. Among adults with constipation, 25.6% (95% CI: 22.8-28.4) …

Integrating Geriatric House Call Practice Into Paramedic Education: A Novel Educational Approach On Attitudes And Acceptance, Phillip D. Magidson, Mariah L. Robertson, Robby May, Mattan Schuchman, Eric Garfinkel, Matthew J. Levy

Journal of Geriatric Emergency Medicine

Objective: This study aimed to assess the feasibility and acceptance of integrating geriatric house call practice clinical exposure into paramedic education and to explore the impact on attitudes towards older adults among paramedic students.

Methods: Paramedic students from a fire department training program participated in a geriatric house call practice in collaboration with an academic health system. Pre- and post-program surveys were conducted to evaluate changes in attitudes towards older adults using the Ageing Semantic Differential (ASD) scale. Patient feedback on paramedic involvement was collected through post-visit surveys.

Results: Six paramedic students completed 25 house call visits over eight weeks. …

Left, Then Right Internal Carotid Artery Dissection: A Case Report, Jeffrey M. Kalczynski, John Douds, Michael E. Silverman

SKMC Student Presentations and Publications

INTRODUCTION: We present a unique case of a patient who presented to the emergency department with stroke-like symptoms found to have a spontaneous, left-sided internal carotid artery dissection (ICAD).

CASE REPORT: The patient was treated successfully with thrombectomy and subsequently developed contralateral symptoms caused by a right-sided ICAD. This was managed with a second contra-lateral thrombectomy. The patient's course was complicated by persistent and mild hypotension, postulated to be secondary to bilateral carotid baroreceptor trauma from the dissections.

CONCLUSION: This case highlights the importance of close neurological monitoring for patients, preferably in a neurologic critical care setting, during and after …

Spontaneous Rupture Of A Splenic Artery Aneurysm With Hemoperitoneum; Case Presentation, Vlad Denis Constantin, Ion Motofei, Gelu Valentin Stefanescu, Adrian Silaghi

Journal of Mind and Medical Sciences

Aneurysms of the splenic artery are relatively rare, being found in patients with portal hypertension, multiparous, atherosclerosis, or in young people with various genetic diseases. In the uncomplicated forms, splenic artery aneurysms are often difficult to diagnose either because of the asymptomatic evolution, or because of the non-specific symptoms. In cases of trauma or large sizes, aneurysms can be complicated by rupture, which can cause hemoperitoneum with the risk of death if specific treatment is not initiated as soon as possible. Depending on the location of the splenic aneurysm, comorbidities, the patient's general condition or life-threatening complications, laparotomy, laparoscopy, endovascular …

Enhancing Patient Safety: The Role Of Interdisciplinary Teams In Reducing Blood Culture Contamination, Austin Patrick Eisenberg, Fady M. Awad, Brian Watson, Mohammed Faris

HCA Healthcare Journal of Medicine

Background

Blood cultures are vital to diagnostic workups among many hospitalized patients, providing valuable information about bloodstream infections (BSIs), which cause roughly 250 000 deaths annually between North America and Europe. Despite advances in health care, blood culture contamination remains a substantial problem, with deleterious effects on patient mortality, patient and hospital costs, and microbial resistance. This article reviews the repercussions of blood culture contamination on the health care system and delineates evidence-based strategies to decrease contamination rates.

Methods

To reduce blood culture contamination rates, our health care facility undertook a quality improvement initiative. A task force was created, consisting …

Revitalizing Emergency Rooms Nationally: Strategies And Insights, Jeffin Dejanovich, Noah Zanville

HCA Healthcare Journal of Medicine

Throughout the United States, the post-COVID-19 pandemic period has been marked by profound disruption to health care operations, coordination, and care capacity. These disruptions have been especially serious in the emergency room (ER) setting. While intensely challenging, the post-pandemic period has also presented opportunities for health care systems to approach classic challenges facing the ER with fresh eyes. In this editorial, the authors discuss key strategies being used to help revitalize ERs nationally and reflect on future challenges and directions.

Long Covid Among Undocumented Latino Immigrant Populations In The Emergency Department., Karen P. Reyes, Zubaid Rafique, Brian Chinnock, Vijaya Arun Kumar, Michael Gottlieb, Kristin L. Rising, Robert M. Rodriguez

Department of Emergency Medicine Faculty Papers

Although many investigators have examined post–COVID-19 condition (long COVID) and its effects in the general population, to our knowledge, no studies have investigated its effect on one of the largest underserved US populations: undocumented Latino immigrants.¹ This group comprises 7% of the US population and has high rates of uninsurance, limited access to primary care, and language barriers when seeking health care.^2-4 Anti-immigrant political rhetoric and immigrants’ fear of discovery of their undocumented status when accessing health care make evaluation of this population more challenging.⁵ We leveraged emergency departments (EDs) as the primary health care …

Association Between Neuromuscular Blocking Agents And Outcomes Of Emergency Tracheal Intubation: A Secondary Analysis Of Randomized Trials, Stephanie C. Demasi, Wesley H. Self, Neil R. Aggarawal, Michael D. April, Luke Andrea, Christopher R. Barnes, Jason Brainard, Veronika Blinder, Alon Dagan, Brian Driver, Kevin C. Doerschug, Ivor Douglas, Matthew Exline, Daniel G. Fein, John P. Gaillard, Sheetal Gandotra, Kevin W. Gibbs, Adit A. Ginde, Stephen J. Halliday, Jin H. Han, Taylor Herbert, Kevin High, Christopher G. Hughes, Akram Khan, Andrew J. Latimer, Amelia W. Maiga, Steven H. Mitchell, Derek J. Vanderhaar, James E. Walker, Et Al

School of Medicine Faculty Publications

Study objective: To examine the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt and severe complications during tracheal intubation of critically ill adults in an emergency department (ED) or ICU. Methods: We performed a secondary analysis of data from 2 multicenter randomized trials in critically ill adults undergoing tracheal intubation in an ED or ICU. Using a generalized linear mixed-effects model with prespecified baseline covariates, we examined the association between the neuromuscular blocking agent received (succinylcholine versus rocuronium) and the incidences of successful intubation on the first attempt …

Pandemic Perspectives From Detained Youth During Covid-19: Bridging The Knowledge Gap For Future Safeguards., April Mcneill-Johnson, Zuri Hudson, Brittany Moore, Dumebi Okocha, Megha Ramaswamy, Kimberly Randell

Manuscripts, Articles, Book Chapters and Other Papers

Despite the worsening health disparities among youth in detention during the COVID-19 pandemic, there has been minimal exploration into the pandemic experiences of detained youth and opportunities for pandemic mitigation. This paper analyzes the perspectives of youth in detention on the pandemic, including the effect of the pandemic on their detention experience and their perceptions about COVID-19 vaccination. The study used purposive sampling to recruit 16 participants (aged 14-17 years) from two juvenile detention centers in the urban Midwest. We conducted semi-structured interviews and analyzed verbatim transcripts using a hybrid deductive-inductive approach and thematic analysis. Four themes emerged: 1) personal …

Emergency Physicians Perspectives Of State Continuing Medical Education Requirements For Medical Licensure, Marianne Gausche-Hill, Yachana Bhakta, Michael C. Bond, Sandra M. Schneider, Jeffrey Druck, Colleen E. Livingston, Lisa Moreno-Walton, Jonathan S. Jones, Melissa A. Barton

School of Medicine Faculty Publications

Objectives: This study aims to better understand the perspectives of emergency medicine physicians’ on the role that state-mandated, topic-specific continuing medical education (CME) plays in addressing knowledge gaps, its relevance to current emergency practice, its reported burden and costs of CME activities to emergency physicians, and its perceived improvement in patient care. Methods: A cross-sectional survey was designed by the Coalition of Board-Certified Emergency Physicians (COBCEP) and distributed in February 2023 to all American Board of Emergency Medicine (ABEM)-certified physicians. Statistical tests of significance (Pearson's chi-square and Fisher's exact test) assessed the cost and time spent on CME as well …

Assessing The Usability Of Iprepared: An Application-Based, Non-Pharmacological Delirium Prevention Intervention, Luke S. Sztajnkrycer, Ian Ward Maia, Heidi Lindroth, Kayla P. Carpenter, Derek Vanmeter, Samantha Gracia, Grace Herbeck, Aidan Mullan, Molly M. Jeffery, Fernanda Bellolio

Journal of Geriatric Emergency Medicine

Introduction: Non-pharmacologic prevention measures reduce incident delirium by up to 30-40%% in inpatient and ED settings, but consistent application is often difficult. A mobile health application, titled iPREPARED (Improve Prevention and Recovery by Engaging Patients and FAmily-Caregivers to End Delirium) was co-developed with patients and their care partners to prepare them for delirium and empower them to use non-pharmacological prevention measures. This study assessed the feasibility, acceptability, and usability of iPREPARED in the emergency department (ED).

Methods: An IRB-approved prospective study enrolled a convenience sample of ED patients over age 60 and/or their care partners. Participants were provided a tablet …

Technical Pitfalls For Fenestrated-Branched Endovascular Aortic Repair Following Petticoat, Aidin Baghbani-Oskouei, Emanuel R Tenorio, Marina Dias-Neto, Andrea Vacirca, Aleem K Mirza, Naveed Saqib, Bernardo C Mendes, Laura Ocasio, Thanila A Macedo, Gustavo S Oderich

Faculty, Staff and Student Publications

Purpose: The Provisional Extension to Induce Complete Attachment Technique (PETTICOAT) uses a bare-metal stent to scaffold the true lumen in patients with acute or subacute aortic dissections. While it is designed to facilitate remodeling, some patients with chronic post-dissection thoracoabdominal aortic aneurysms (TAAAs) require repair. This study describes the technical pitfalls of fenestrated-branched endovascular aortic repair (FB-EVAR) in patients who underwent prior PETTICOAT repair.

Technique: We report 3 patients with extent II TAAAs who had prior bare-metal dissection stents treated by FB-EVAR. Two patients required maneuvers to reroute the aortic guidewire, which was initially placed in-between stent struts. This was …

Emergency Physicians Spend More Time Caring For Patients Who Prefer A Language Other Than English Which May Not Be Accounted For In Reimbursement Structures, Martin A Reznek, Jennifer Edwards, Sean S Michael, Jacqueline Furbacher, Alexandra Sanseverino, Payal K Modi, Kevin A Kotkowski, Celine Larkin

Faculty, Staff and Student Publications

Background: Emergency departments increasingly serve patients who prefer a language other than English. Honoring patients' language preferences is crucial for quality and cultural appropriateness of care. We sought to assess whether time spent in caring for patients who preferred a language other than English differed from patients whose language preference was English. Secondarily, we sought to assess professional reimbursement across the two groups.

Methods: We retrospectively analyzed an existing dataset from a time-in-motion study that included direct observation measurements of emergency physicians' time spent during patient encounters. Our primary outcome was physician time spent conducting patient care, comparing patients who …

Transcription And Post-Translational Mechanisms: Dual Regulation Of Adiponectin-Mediated Occludin Expression In Diabetes, Yanru Duan, Demin Liu, Huahui Yu, Shihan Zhang, Yihua Xia, Zhiyong Du, Yanwen Qin, Yajing Wang, Xin-Liang Ma, Huirong Liu, Yunhui Du

Department of Emergency Medicine Faculty Papers

BACKGROUND: Occludin, a crucial component of tight junctions, has emerged as a promising biomarker for the diagnosis of acute ischemic disease, highlighting its significant potential in clinical applications. In the diabetes, Occludin serves as a downstream target gene intricately regulated by the adiponectin (APN) signaling pathway. However, the specific mechanism by which adiponectin regulates Occludin expression remains unclear.

METHODS AND RESULTS: Endothelial-specific Ocln knockdown reduced APN-mediated blood flow recovery after femoral artery ligation and nullified APN's protection against high-fat diet (HFD)-triggered apoptosis and angiogenesis inhibition in vivo. Mechanically, we have meticulously elucidated APN's regulatory role in Occludin expression through a …

Increasing The Frequency Of Behavior Assessment To Reduce Physical Restraint, Breanne N. Ford

Doctor of Nursing Practice Final Project Abstract

Purpose: The purpose of this quality improvement (QI) project was to implement a system that routinely assesses for behavior changes in psychiatric patients presenting to the emergency department to improve staff intervention of escalating behaviors and decrease physical restraint use.

Background: The project was implemented in a 45-bed emergency department in a community-based hospital affiliated with a large hospital system in Houston, Texas.

Methodology: The project utilizes the Behavioral Activity Rating Scale (BARS) to assess patients' behaviors at routine intervals throughout shifts and a comfort cart that houses several non-pharmacological intervention items to use to de-escalate adverse behaviors. The staff …

Spontaneous Spinal Epidural Hematoma Presenting As A Stroke Alert: A Case Report, Christian Flores Do, Monisha Bindra Do, Mph, Adam Sigal Md, Michael Romeo Do

Transformative Medicine

Introduction

Spinal epidural hematoma (SEH) is a rare pathologic entity that accounts for less than 1% of all space-occupying spinal canal lesions [2,8]. Even more rare are spontaneous spinal epidural hematomas (SSEH), defined as a SEH without a known traumatic or inciting cause, with a reported incidence of 0.1 cases per 100,000 annually [1,2]. Currently, there is a paucity of literature regarding this topic [2,3]. SSEH can easily be missed or misdiagnosed if clinicians do not hold a high level of clinical suspicion.

Case Description

A 69-year-old female with no history of anticoagulation use or preceding trauma presented to the …