Emergency Medicine Commons^™

Out Of Time: Altered Mental Status And Temporal Seizure On Background Of Dementia & Uti, Jennifer Nguyen, Victoria Wong Murray, Judith Anne Lightfoot, Mukarram Razvi, Kasturi Etukuru

Rowan-Virtua Research Day

Herpes simplex virus is common in the US, with an estimated seroprevalence of HSV-1 of 40% and HSV-2 of 11%. Although herpes encephalitis is rare, with an incidence of roughly 1/100,000 individuals per year in the US, the mortality rate of 70% and rapid progression make identification and treatment imperative.

An 85 year old woman was brought to the emergency department from nursing home with altered mental status of unknown duration in refractory status epilepticus on a background of dementia, history of multiple falls, and indwelling foley catheter in addition to hypertension and bilateral knee replacement. EEG demonstrated abnormal discharges …

Ketamine Crisis: Case Report On The Complications Of Ketamine Usage And Its Rise In The United States, Shika Veera, Vajreshwari Shivaprakash

Rowan-Virtua Research Day

The recreational use of ketamine poses various health risks, including addiction, cognitive impairments, and physical harm.

The patient is a 24-year-old female who presented with 30 lbs. unintentional weight loss, generalized weakness, and urinary incontinence over four months. She endorses right upper quadrant and suprapubic pain with occasional gross hematuria. The patient denied recreational drug use. Urine drug screen was negative. Gynecologic exam and STI testing were without concerns. On exam, she had positive right lower quadrant tenderness, suprapubic tenderness, and costovertebral angle tenderness bilaterally. The patient was admitted to the ICU due to weakness and significant hyponatremia at 115. …

Bridging Gaps In Opioid Use Disorder Treatment: Prehospital And Emergency Department Interventions, Quin W. Buob, Zachary J. Noll

Rowan-Virtua Research Day

Since 2011, drug overdose has been the leading cause of accidental death in the United States, with two-thirds of these deaths related to opioid drugs. In 2020, the CDC reported an increase of over 91,000 overdose-related deaths. Also, non-fatal overdoses face a 5.5% one-year mortality rate post discharge, with a significant portion subsequently overdosing within 48 hours.

Access to Buprenorphine/Medication-Assisted Treatment (MAT) has been instrumental in reducing opioid-related mortality by over two-thirds, yet treatment initiation remains significantly low. Limited access stems from socioeconomic disparities and insufficient substance use treatment resources.

Emergency departments (EDs) have pioneered Buprenorphine inductions, showcasing variable success …

Moving On Up: A Case Study Of Hiv And Covid-Induced Guillain-Barre Syndrome, Victoria Wong Murray, Rebecca Chae, Isobel Moyer, Cindy Hou

Rowan-Virtua Research Day

COVID and HIV are both common diseases, with COVID affecting an estimated 775 million and HIV affecting 39 million people worldwide. Guillain-Barre is a rare but feared complication of immune stimulation in which the body generates autoantibodies against gangliosides, found in the nodes of Ranvier, in the myelin, and in the ganglia; causing ascending paralysis.

A mid-30s man with HIV maintained on Genvoya presented to the Jefferson Health New Jersey Early Intervention Program clinic with fatigue, fever, cough, and congestion and tested positive for SARS-CoV-2 on the following day. Two weeks later, he presented to the emergency department complaining of …

Case Report: Post-Obstructive Pneumonia Secondary To Foreign Body Aspiration, Aashna Chaudhry, Andrew Vasta

Rowan-Virtua Research Day

Post-obstructive pneumonia is described as a pulmonary infiltrate that occurs proximal to the site of an obstructed bronchus. Studies show that post-obstructive pneumonia most commonly secondary to obstruction caused by neoplasms. According to a study done on post obstructive pneumonia in lung cancer, most cases of post obstructive pneumonias are associated with advanced neoplasms with up to 50% of those with advanced cancer getting endobronchial compromise. While neoplasms are the most common cause of post obstructive pneumonia, research is scarce on other potential causes of post obstructive pneumonia. This case reports presents a unique clinical case in which an adult …

Case Report: Overdrive Pacing In Refractory Ventricular Tachycardia, Alyssa A. Baldini, Kishan B. Patel

Rowan-Virtua Research Day

We report a case of a 67-year-old male who presented to the emergency department (ED) for palpitations and complaint of his automated implantable cardioverter defibrillator (AICD) firing at home who had multiple episodes of persistent ventricular tachycardia (VT) during his course of stay in the ED. Patients with pacemakers and AICDs can present an additional layer of complexity when treating these conditions. Temporary overdrive pacing (TOP) should be considered as a treatment to correct refractory ventricular tachycardia in patients with implanted pacemakers and AICDs presenting to the ED.

Case Report: What’S That Smell? Olfactory Seizures, Devin Hoover, Neelesh Parikh, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

We report a case of a 64-year-old male who presented with transient episodes of near syncope followed by a noxious odor and was diagnosed with olfactory seizures. The differential diagnosis for near syncope is broad. This case demonstrates that unusual olfactory symptoms can lead to a diagnosis of seizure disorder in the emergency department.

Case Report: An Emergency Department Presentation Of An Ovarian Teratoma, David Marconi, Zamron Masih

Rowan-Virtua Research Day

A teratoma (from the Greek terato for “monster” and onkoma for “mass” or “swelling”) is a type of neoplasm composed of tissues from two or three germ layers. Mature cystic teratomas (MCTs) constitute 70% of all ovarian neoplasms. They typically present with nonspecific symptoms such as pain and nausea. They account for approximately 2% of all primary ovarian malignant cancers and are predominately diagnosed via ultrasound. Computed tomography may be necessary if malignancy is suspected. Larger size warrants a higher suspicion of malignancy. Management is symptom control and ultimately, surgical removal. Prognosis is generally excellent, provided there is no malignant …

Spontaneous Intracranial Hemorrhage In A 29-Year-Old Male: A Case Report, Md Fateha, Caroline Nguyen, Michael A. Morris

Rowan-Virtua Research Day

Spontaneous intracranial hemorrhage is rare, especially in a young patient population. Signs and symptoms of intracranial hemorrhage include facial droop, vision loss, motor deficits with extraocular movements, deficits with tongue movement, weakness in the arms or legs, sensation loss, and mental status change. This is a case report of a 29-year-old male with no past medical history who presented for a spontaneous intracranial hemorrhage. This patient's only neurologic deficit was the loss of visual field on the left inferior quadrant of his field of vision. The patient obtained a CT head non-contrast which showed 21 mm acute right occipital hemorrhage …

Atypical Case Of Recurrent Saddle Pulmonary Embolism With Associated Chronic Hypoxia, Karl Schlicht

Rowan-Virtua Research Day

A saddle pulmonary Embolism (PE) represents a blood clot within the pulmonary artery vasculature that lodges itself between both the left and right pulmonary artery. They can be described as being massive or sub-massive. Massive PE’s cause large clot burden that puts the patient risk for sudden hemodynamic collapse, while sub-massive saddle PE’s typically do not cause hemodynamic collapse nor significant cardiac effects, such as right heart dysfunction. As clinicians, we need to be vigilant about whether a patient is placed into that criteria of sub-massive or massive and act quickly to start management that could be lifesaving.

‘Not So Atypical’: An Atypical Presentation Of West Nile Virus And Guillain-Barre Syndrome, Matthew Orap, Sana Tahir, Ugonna Ononuju, Naresh Kumar

Rowan-Virtua Research Day

Guillain-Barre Syndrome (GBS) is defined by acute areflexic paralysis, usually starting in the distal lower extremities, and ascending to the upper extremities. It is associated with albuminocytologic dissociation, which involves elevated protein levels and normal cell counts in the cerebrospinal fluid. One of the types of GBS, called Miller-Fischer Syndrome (MFS), is characterized by ophthalmoplegia, ataxia, and areflexia. This case report focuses on a 49-year-old male with an atypical presentation of Guillain-Barre syndrome. Guillain-Barre syndrome can be classically caused by Campylobacter jejuni. However, there can be other infectious causes as well, namely Cytomegalovirus, Epstein-Barr virus, Varicella-Zoster virus, …

Case Report: Varicella Zoster Virus Encephalitis Presenting With Monochorea, Chetna Thawani, Frank Wheeler

Rowan-Virtua Research Day

Meningoencephalitis is a broad range of symptoms as a sequela of inflammation of the CNS system. It is a diagnosis that is often missed, especially in atypical presentations. We describe a case of HSV encephalitis that presented to the ER afebrile with atypical arm movements, most similar to a monochorea, and discuss other cases in the literature of atypical presentations of this disease.

Wellen’S Syndrome: An Infamous Example Of Occlusive Myocardial Infarction (Omi), Joseph Maxwell Piraneo, Joseph Pagano, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Wellen’s syndrome is a condition with characteristic ECG changes that can be highly specific for acute myocardial infarction involving the left anterior descending (LAD) artery. Acute myocardial infarctions are one of the leading causes of death in the developed world. Its estimated annual prevalence is nearly 3 million worldwide, with more than 1 million in the United States [1]. The importance of timely diagnosis cannot be understated. Here we describe a case of myocardial infarction secondary to LAD occlusion which presented with the atypical ECG pattern known as Wellen’s syndrome.

Case Report: Babesiosis Presenting To The Emergency Department, Daniel M. Zaayenga, Daniel A. Weeks

Rowan-Virtua Research Day

Babesiosis is a tick-borne illness caused by the parasitic protozoa Babesia transmitted by the Ixodes tick. Babesia infect the red blood cell of its host and requires the cell for its replication. It is a disease process that can range from asymptomatic infection to organ failure and death. This case presentation reviews a 68-year-old male who presented to the emergency department with flu like symptoms and was found to have babesiosis.

Chilling Complications: A Case Of Covid-Associated Cold Autoimmune Hemolytic Anemia (Aiha), Julian Coz, Kishan B. Patel

Rowan-Virtua Research Day

Cold Agglutinin disease (CAD) also known as Cold Autoimmune Hemolytic Anemia (AIHA) is a form of autoimmune hemolytic anemia wherein cold agglutinins (IgM autoantibodies against red blood cell (RBC) antigens) bind during cold temperatures causing clinical symptoms related to RBC agglutination resulting to hemolytic anemia. Clinicians should recognize that Cold Agglutinin disease can be secondary to an underlying pathology such as COVID-19. Here we describe an unusual case of Cold Agglutinin Autoimmune Hemolytic Anemia which was diagnosed in the Emergency Department with the presence of COVID-19 and with a hospital course complicated by acute deep vein thrombosis (DVT) and bilateral …

A Case Of Esophagogastric Junction Outflow Obstruction Resulting To Megaesophagus In A 37-Year-Old Male, Dean Esma, Robin Lahr, James A. Espinosa, Alan Lucerna

Rowan-Virtua Research Day

Esophagogastric junction outflow obstruction (EGJOO) is a major motility disorder characterized by an increase of > 15 mmHg in the integrated relaxation pressure (IRP) with or without problems in esophageal motility. This presents as dysphagia, chest pain, regurgitation, heartburn, cough, and a globus sensation, with dysphagia. Severe cases may lead to a megaesophagus causing compression of mediastinal structures.6 Its similarity to other esophageal disorders urge an investigation to improve its identification and treatment. This report presents a case of EGJOO in a 37-year-old cachectic male patient with dysphagia and vomiting, eventually determined to be EGJOO with diagnostic manometry.

Quincke’S Phenomenon – The Ace Inhibitor Culprit, Mohammad A. Rattu, Eric A. Maddock

Rowan-Virtua Research Day

Angioedema is defined as a non-pitting edema that involves the subcutaneous layer and additionally may include submucosal layers of tissue which pertain to the face, oral cavity, larynx, lips, extremities and gastrointestinal tract; this becomes a life-threatening situation particularly when there is involvement of the larynx. Angioedema may be classified as either histamine-mediated or bradykinin-mediated. Histamine-mediated, associated with mast-cell and basophil activation, is the most common. Bradykinin-mediated (secondary to hereditary, acquired C1-inhibitor deficiency, ACEI-associated angioedema) occur when an allergic reaction and hives will not trigger this reaction. The C1-inhibitor is a regular of the complement system and either dysfunction or …

A Rare Presentation: Intracranial Hemorrhage As A Symptom Of Acute Leukemic Transformation In A 23-Year Old Male, Kelsey M. Murray, Kishan B. Patel

Rowan-Virtua Research Day

This case highlights the urgency of considering acute leukemic transformation in young patients presenting with neurological deficits, emphasizing the importance of prompt evaluation and management to optimize patient outcomes. The case depicted is a tragic complication of Chronic Myeloid Leukemia (CML) and its acute blast crisis. Remarkably, the patient exhibited none of the typical constitutional symptoms associated with CML.

Cancer Screening Guidelines In Midwest Adult Correctional Facilities, Stephen Greenwell, Jason Adam Wasserman

Posters

National cancer screening guidelines (CSGs) exist to promote early cancer detection, reducing mortality, morbidity, and cost. The incarcerated population is at increased risk for certain cancers, decreased cancer screening, and barriers to treatment. In this study we investigate how state and federal prison CSGs differ from the National Comprehensive Cancer Network’s (NCCN) CSGs.

Using Age-Adjusted D-Dimer Vs Traditional D-Dimer To Rule Out Acute Aortic Syndrome, Jacob Nelson, Divyani Patel, Sylvia Kashat, Gorune Geloian, Karen Childers, David A. Berger, Brett Todd

Conference Presentation Abstracts

Background and Objectives: Acute aortic syndromes (AS), including aortic dissection, are rare and life-threatening diagnoses. Early diagnosis is critical as mortality increases by 1%–2% per hour after symptom onset. D-dimer (DD) Methods: In this retrospective chart review, we identified all patients who presented to any Emergency Department (ED) at a multicenter health system between 2012 and 2021, received a D-dimer test, and underwent CTA Dissection, CTA Coronary Study, or CTA Triple Rule-Out. Patients under the age of 18, pregnant, had prior dissection or thoracic aorta repair, or who presented altered/unresponsive were excluded. For patients with multiple presentations, the first visit …

Evaluating Blood Pressure Methods In Non-Traumatic Intracerebral Hemorrhage: A Two-Site Prospective Observational Study, Desiree Cihelka

Theses and Dissertations (ETD)

Purpose. Blood pressure (BP) management is difficult and complex in the treatment of acute non-traumatic intracerebral hemorrhage (ICH). Despite mean arterial pressure (MAP) being the most reliable measure of noninvasive automatic oscillometric (NIBP) in clinical practice, clinicians instead rely on systolic and diastolic blood pressure (SBP and DBP) values to guide clinical practice. Given the widespread use of NIBPs for obtaining BP values in the acute care setting, we determine the agreement between SBP, DBP, and MAP measured by NIBP, manual cuff, and Arterial lines (A-lines) in patients with ICH. Study Aims. To understand the agreement between SBP, DBP, and …

Emergency Department Treatment Of Elevated Blood Pressure In The Headache Patient, Lauren Eberhardt, Michelle Jankowski, Brett Todd

Posters

• Headache is an extremely common emergency department (ED) chief complaint, accounting for 1-3% of emergency department (ED) visits per year globally.
• Headache is often associated with elevated blood pressure and the most frequent clinical manifestation of hypertensive urgency, occurring in 35.9% of patients.5
• First line treatments used for acute headache management in the ED include intravenous fluid (IVF), anti-dopaminergic agents, aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and ketorolac.6
• Rescue analgesia is needed for pain management in 16% to 18.1% of patients.8,9.
• Rescue analgesia includes: additional doses of first line analgesia or initiation of a second line medication1,6,10,11 such as magnesium sulfate, …

Characterizing The Effectiveness Of Prehospital Pediatric Pain Management In Children With Long Bone Fractures, Revelle Gappy, Ashima Goyal, John Frawley, Sariely Sandoval, Nai-Wei Chen, Remle Crowe, Robert Swor

Posters

Prehospital pediatric pain management has been poorly understood and sub-optimally treated.1-3 Pain scales for children differ from adult pain scales and it is unclear if pain assessments are well documented, particularly in infants and toddlers.4-6 Surveys of emergency medical services (EMS) personnel identify barriers to pain management including discomfort with emergency care of injured children, concern for allergic reactions, additional pain from intravenous catheter insertion, parental influence, as well as lack of knowledge and experience secondary to the relatively infrequent treatment of acutely injured children.7-9

The effectiveness of prehospital pain medication administration for children is unknown, as is the efficacy …

Comparing Outcomes Of Mechanical And Manual Cardiopulmonary Resuscitation In Out-Of-Hospital Cardiac Arrest: A Retrospective Cohort Study, Margaret Beyer, Fabirce I. Mowbray, Nicole Wannis, David A. Berger, Christine M. Brent, Robert Dunne, Theresa A. Shields, Matthew T. Ball, Joseph Miller, Howard Klausner

Conference Presentation Abstracts

Background and Objectives: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death in the United States, with over 350,000 per year. Despite improvements in care, OHCA outcomes remain low. Chest compressions can be administered manually or via an automated mechanical device. Mechanical CPR (mCPR) devices are designed to achieve return of spontaneous circulation (ROSC) by delivering consistent compression depth and rate. This retrospective cohort of the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) compared survival to hospital discharge with good neurological status (CPC 1 or 2) between manual and mechanical CPR. Methods: The CDC collaborated with Emory University …

Diuretic Dose Ratio Is Associated With Reduced Hospital Length Of Stay In Acute Heart Failure, Sarah Galla, Yuying Xing, Lihua Qu, David A. Berger

Conference Presentation Abstracts

No abstract provided.

Cardiac Magnetic Resonance Imaging Reduces Radiation Exposure In Emergency Department Patients With Chest Pain, Cedric W. Lefebvre, Anna C. Snavely, Nicklaus P. Ashburn, Nathanael Franks, Robin Rainey Kiehl, Simon A. Mahler, Jason P. Stopyra, Lauren E. Koehler, Brian C. Hiestand, Sujethra Vasu, Michael A. Hall, Alan E. Jones, Carol L. Clark, Jeffrey M. Caterino, Subha V. Raman, Chadwick D. Miller

Conference Presentation Abstracts

Background and Objectives: Patients presenting to the Emergency Department (ED) with chest pain who have an indeterminate (detectable to mildly elevated) troponin are often further evaluated with tests that use ionizing radiation. We hypothesized that patients initially evaluated with stress cardiac magnetic resonance (CMR) imaging receive less ionizing radiation through 1-year of follow-up than those initially evaluated with invasive angiography. Methods: We conducted a secondary analysis of the CMR-IMPACT trial, which randomized adult patients at 4 U.S. sites (9/2013– 7/2018) with a contemporary troponin of 0.006–1.0 ng/mL to either CMR imaging or invasive angiography. Cumulative radiation exposure from coronary computed …

Screen Positives For Potential St-Segment Elevation Myocardial Infarction: Door To Electrocardiogram By Sex And Race, Sarah Galla, Gautam Pathak, Dalia Owda, Amit Bahl, James Ziadeh, Susan Bork, Robert Swor, Karen Childers, Maya Yiadom, David A. Berger

Conference Presentation Abstracts

Background and Objectives: Detection of ST-segment elevation myocardial infarctions (STEMI) are dependent on early acquisition of an ECG. American Heart Association guidelines require performing an ECG within 10 min for patients presenting with symptoms warranting STEMI screening. A delay in ECG acquisition causes delays in diagnosis and treatment, which is associated with worsened outcomes. However, previous work has shown there is limited success at achieving a door to ECG (D2E) time of Methods: This is a retrospective chart review study in which D2E time was measured for patients positive for STEMI ECG screening criteria in a large health system with …

Diuretic Dose Ratio Is Associated With Reduced Hospital Length Of Stay In Acute Heart Failure, Sarah Galla, Yuying Xing, Lihua Qu, David A. Berger

Conference Presentation Abstracts

Background and Objectives: Congestive heart failure (CHF) is anticipated to affect eight million Americans by 2030. Treatment for CHF exacerbation is centered around IV diuretics. There are no current studies indicating an optimal initial diuretic dose in the Emergency Department (ED), and our objective is to test our hypothesis that higher diuretic dose ratio may shorten hospital length of stay (LOS). Methods: We conducted a retrospective cohort study of a large health system from 2016 to 2022. We included patients admitted from the ED with a primary diagnosis of “CHF exacerbation” with a history of CHF and prescribed diuretics. Exclusions …

Lactate Expression, Mortality, And Length Of Stay In Emergency Department Patients With Sepsis And Intubation, Heaveen Ahdi, Nadine Talia, Ray Lee, Lili Zhao, Ronny Otero, David A. Berger

Conference Presentation Abstracts

Background and Objectives: Studies demonstrate that patients in septic shock with a lactate < 2 have a mortality between 20% to 46%. Our prior work reported that in emergency department (ED) patients with a second lactate ≥2 (lac), there is a two-fold increase in 30-day mortality when compared to patients with a second lactate < 2 (alac). On secondary analysis, we found that intubated patients with a second lactate ≤2 had a longer hospital length of stay (LOS). Our objective is to further scrutinize this 30-day mortality and LOS. Methods: This is a retrospective cohort study of an eight-hospital health system using data from the electronic medical record. Inclusion criteria consisted of patients ≥18 years of age who presented to the ED from 1/1/2017 to 11/30/2022 with ≥2 lactate levels measured in the ED, were diagnosed with sepsis, and admitted to the intensive care unit (ICU) within 24 h. We excluded lactate auto-expressors, pregnant patients, transfers, and those taken for a surgical procedure within 72 h of presentation. Patients were classified based on initial and second lactate as < 2 (alac) or ≥2 (lac). Multivariable regression analysis was performed for 30-day mortality and LOS, adjusting for vitals, BMI, DNR status, and intubation timing. Results: Of the 3100 patients who met inclusion criteria, 1285 patients were intubated and categorized based on their lactate expression: alac -> alac (reference; 111/1285, 8.9%), alac -> lac (28/1285, 2.2%), lac -> alac (259/1285, 20.2%), and lac -> lac (887/1285, 69.0%). Lac -> lac had a significantly higher 30-day mortality (OR = 2.058, 95% CI = [1.353–3.154]) compared to alac -> alac. Lac -> alac had a significantly increased LOS (OR = 1.133 (95% CI = [1.003–1.280]) compared to alac -> alac. Other group comparisons for 30-day mortality and LOS were not significant. Conclusion: Intubated sepsis and septic shock patients in the lac -> lac group had a …

The Rural Medicine Curriculum: The Missing Piece Of Urban Residency Education, Robert Calleja, Bophal Hang

Conference Presentation Abstracts

Intro/Background: Critical Access Hospitals (CAHs) have staffing shortages as most recent graduates of emergency medicine (EM) recidency programs pursue jobs in urban environments. It is presumed that this is due to limited exposure to rural EM scenarios throughout training, leading to hesitancy to practice in these situations as a new graduates with minimal single provider experience. Review of MedEd Portal demonstrates no curriculum filling this deficit in EM training, leading to the development of this curriculum. Purpose/Objective: The goal of the curriculum was to inspire further interest and preparedness to work in rural/critical access hospitals (CAHs). The hope was that …