Emergency Medicine Commons^™

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.

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 …

Vesicant Infusates Are Not Associated With Ultrasound-Guided Peripheral Intravenous Catheter Failure: A Secondary Analysis Of Existing Data, Mahmoud Hijazi, Amit Bahl, Nai-Wei Chen

Posters

With over 300 million used annually in the United States, peripheral intravenous catheters (PIVC) are the most commonly used invasive device in the acute care setting1,2. Unfortunately, PIVCs have high failure rates with up to 63% failing prematurely3,4.

Certain intravenous medications categorized as vesicants and irritants are known to cause vein and local tissue injury. The Infusion Nursing Society (INS) created this list based on infusate osmolarity thresholds that increase the likelihood of these complications5.

It is perceived the impact of these medications on larger proximal veins with higher flow rates and improved hemodilution diminishes the likelihood of these complications. …

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 …

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.

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 …

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 …

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 …

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 …

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 …

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 …

The Employment Of Resuscitative Endovascular Balloon Occlusion Of The Aorta In Deployed Settings, Branson D. Taheri, Andrew D. Fisher, Ian F. Eisenhauer, Michael D. April, Julie A. Rizzo, Sundeep S. Guliani, Kathleen M. Flarity, Michael Cripps, Vikhyat S. Bebarta, Max V. Wohlauer, Steven G. Schauer

Faculty Publications

Excerpt: We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%).