Quality Improvement Curriculum for Intensive Care Unit Upgrades.

Patients admitted to the hospital ward from the emergency department (ED) occasionally decompensate and require transfer to the intensive care unit (ICU). An emergency medicine (EM) curriculum focused on review of these ICU upgrade cases could improve resident knowledge related to patient acuity, critical illness, and appropriate disposition. Furthermore, initial identification of critical pathology in the ED and earlier admission to the ICU could reduce delays in care and improve patient outcomes. We performed a retrospective analysis to determine the effectiveness of a resident quality improvement curriculum evaluating cases where patients require transfer from the inpatient floor to the ICU within 12 hours of admission from the ED. We compared postgraduate year 2 (PGY-2) EM residents who participated in the ICU upgrades curriculum during their first year to PGY-2 EM residents who did not participate in the curriculum. Analysis of the 242 qualifying ICU upgrade cases from July 2019-October 2021 showed post-curriculum residents were responsible for an average of 1.0 upgrades per resident compared to an average of 1.54 upgrades per resident (P = 0.12) for pre-curriculum residents. Although there was no statistically significant difference in ICU upgrades between the groups, there was a trend toward decreased ICU upgrade cases for residents who participated in the curriculum. Common reasons for ICU upgrade included worsening respiratory distress requiring higher level of respiratory support, recurrent hypotension after initial intravenous fluid resuscitation requiring vasopressor support, and declining mental status. This retrospective study showed no significant difference in the number of ICU upgrades for residents who completed the ICU upgrades curriculum compared to residents who were not enrolled in the course. However, the study was likely underpowered to detect a significant difference in the groups, and there was a trend toward reduced ICU upgrades for residents who completed the curriculum. ICU upgrade cases were frequently associated with worsening respiratory status, hypotension, and mental status. These findings highlight the importance of reassessment of vital signs and mental status prior to determining disposition from the ED. Additional, larger studies are needed to better determine the curriculum's impact on resident proficiency in recognizing critical illness and reducing ICU upgrades.

A Case Report of the Rapid Evaluation of a High-Pressure Injection Injury of a Finger Leading to Positive Outcomes.

High-pressure injection injuries, though rare, carry high rates of morbidity and amputation despite a potentially benign initial presentation. Emergency physicians must have a high index of suspicion and be ready to act quickly when evaluating this presenting complaint. In this case report, a patient presented to the emergency department with a chief complaint of finger pain after a pressure washer came into contact with his right index finger. He subsequently developed pain, numbness and a white discoloration to his finger surrounding a small puncture wound. Key interventions in his care included rapid assessment, beginning broad spectrum antibiotics, and quickly consulting the hand surgery team. Despite the potential for significant morbidity with this injury, expedited evaluation and treatment in this case allowed for adequate retention of function in the affected digit, with only mildly decreased pincer function. In summary, the early mobilization of resources for patients with high-pressure injection injuries, especially early surgical consultation, is paramount to achieving positive outcomes. Topics: Finger injury, hand injury, high-pressure injection injury.

Evaluation of ACE-inhibitor Induced Laryngeal Edema Using Fiberoptic Scope: A Case Report.

This is a case report of a 55-year-old woman with a past medical history of hypertension who presented to the emergency department with upper lip and cheek swelling isolated to the right side of her face. She was on lisinopril for several years and had never had an episode of swelling in the past. Her vital signs were stable. However, on reassessment, the patient's right sided swelling progressed to the entire upper lip and she complained of swelling in her submandibular space. Although no swelling was appreciated to the submandibular space on physical exam, and the patient still did not have any signs or symptoms of respiratory distress, the decision was made to use a fiberoptic laryngoscope to evaluate her airway. Fiberoptic laryngoscope showed noticeable laryngeal edema which did not improve after treatment, and the patient was admitted to the medical intensive care unit for close airway observation. This case highlights the use of fiberoptic laryngoscope by emergency physicians in the evaluation of patients with relatively benign appearing angioedema. Topics: ACE-I, angioedema, fiberoptic laryngoscope, laryngeal edema, tranexamic acid.

A Case Report of Posterior Communicating Artery Aneurysm Presenting as Cranial Nerve 3 Palsy in a Young Female Patient with Migraines.

This is a case report of a 33-year-old female with a history of migraines who presented with her typical migraine symptoms for three days. However, she also began to notice diplopia and drooping of her right eyelid, which were symptoms she had never had in the past with migraines. MR angiography showed a 4x3x5 mm posterior communicating artery aneurysm that was likely compressing the right third cranial nerve. She was taken to the operating room by neurosurgery and underwent clip ligation of the aneurysm with improvement in symptoms. It is important to always assess for new signs and symptoms in patients presenting to the Emergency Department who are complaining of their "typical" migraine symptoms because this may indicate previously undiagnosed pathology that will require intervention to prevent negative outcomes. Topics: Cerebral aneurysm, cranial nerve palsy, ptosis.