Telemedicine Consult for Shortness of Breath Due to Sympathetic Crashing Acute Pulmonary Edema.

Audience: This simulation is appropriate for senior and junior emergency medicine residents. Introduction: Shortness of breath is a very common presentation in the emergency department and can range from mild to severe as well as a chronic or acute onset. In sympathetic crashing acute pulmonary edema (SCAPE), patients typically present with acute onset of dyspnea occurring within minutes to hours and have significantly elevated blood pressure.1 The condition of SCAPE falls into the spectrum of acute heart failure syndromes such as fluid overload pulmonary edema and congestive heart failure exacerbation.1. Educational Objectives: At the completion of the simulation and debriefing, the learner will be able to: 1) recognize the physical exam findings and presentation of SCAPE, 2) utilize imaging and laboratory results to further aid in the diagnosis of SCAPE, 3) initiate treatments necessary for the stabilization of SCAPE, 4) demonstrate the ability to assist with the stabilization and disposition of a patient via tele-medicine as determined by the critical action checklist and assessment tool below, 5) interpret the electrocardiogram (EKG) as atrial fibrillation with rapid ventricular response (AFRVR), and 6) recognize that SCAPE is the underlying cause of AFRVR and continue to treat the former. Educational Methods: This simulation was performed using a high-fidelity mannequin. In order to simulate the telemedicine aspect, the learner evaluated the patient using a video conferencing interface while the two confederates were present with the high-fidelity mannequin. A debriefing session was held immediately after the simulation. Research Methods: The educational content was evaluated by debriefing and verbal feedback provided immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Results: Post-simulation feedback was overall positive with participants and observers. Participants and observers felt this was a safe and realistic simulation of SCAPE and provided them with the opportunity to practice rapid recognition and treatment of this condition. Discussion: Sympathetic crashing acute pulmonary edema falls into the spectrum of acute heart failure disorders, and rapid recognition and stabilization is vital for the patient's survival. This simulation case provided learners of all levels the chance to assess and treat a life-threatening condition with limited information in a safe and effective learning environment. The telemedicine component was used while conducting weekly didactics via zoom during the COVID-19 pandemic. Simulation is a large component of our didactic curriculum and implementing the telemedicine component into this case was worth the effort. It is important to familiarize our residents with telemedicine since we expect that it will become a larger part of the practice of emergency medicine in the future, allowing board-certified emergency medicine physicians to assist in providing care in rural emergency departments and smaller hospitals that may be staffed with less experienced providers. Topics: Medical simulation, tele-medicine, pulmonary edema, respiratory distress, cardiac emergencies, resuscitation.

Distribution of livestock sectors in Canada: Implications for manureshed management.

Canada's livestock production and human populations are concentrated in southern regions. Understanding spatial and temporal distributions of animals and excreted nutrients is key to optimizing manure resources and minimizing impact of livestock. Here, we identify manureshed concerns and opportunities by reconciling nitrogen supply and demand on a regional and national scale. Data based on national statistics and farm surveys were allocated to homogeneous soil polygons (Soil Landscapes of Canada [SLC]) to quantify changes in nutrient distribution and ammonia (NH3 ) emissions across Canada (1981-2018). Livestock sectors tied to domestic consumption, dairy and poultry, were stable over time and well dispersed. Export driven beef production has moved west since 1981, whereas pig production was prominent in Manitoba, Quebec, and Ontario. Per ha manure N excretion across livestock sectors in 2018 was generally low with 58% and 6% of the SLCs averaging <25 and >100 kg N ha-1 , respectively. Although only 3% of SLCs had average NH3 emissions reaching 16-200 kg ha-1 , most of these were located near cities and emissions spiked in spring when more people might be exposed. The greatest concentrations of nutrients and livestock occurred around the three largest metropolitan areas: Toronto, Montreal-Quebec City, and Vancouver, posing challenges for nutrient recycling and public health. This study shows that as Canadian cities and livestock agriculture grow in southern Canada, so will challenges around food production, human health, and managing nutrients. Livestock and land use strategies are needed to reconcile changing animal sectors and growing populations.

Effects of sustainable agronomic intensification in a forage production system of perennial grass and silage corn on nutritive value and predicted milk production of dairy cattle.

The objectives were to determine the effects of incrementally applied improved nutrient management, alternative cropping practices, and advanced production technologies in a dual forage system of perennial grass and silage corn on nutrient composition and in vitro ruminal fiber digestibility of the forages and, using these data as inputs into the Cornell Net Carbohydrate and Protein System, to predict milk production, indicators of nitrogen (N) utilization, and N excretion of dairy cattle. Farm management systems (farmlets) included a conventional system with whole manure slurry broadcast to a late maturing corn hybrid and grass harvested with 5 cuts per year (F1); improved nutrient management with a separated manure system where the sludge was applied to corn and the liquid was applied to grass (F2); improved nutrient management and alternative cropping practices with separated manure, an early maturing corn hybrid interseeded with a relay winter cover crop, and grass harvested with 3 cuts per year (F3); and improved nutrient management and alternative cropping practices combined with advanced production technologies that included irrigation and a nitrification inhibitor (F4). The field trial was a randomized complete block design over 2 yr with 4 blocks each divided into grass and corn, 4 subplots within each block for each crop, and 2 replicates within each subplot. Diets were formulation with 60% forage and 40% concentrate where the grass and corn as silage was proportional to yield for land allocations of grass and corn of 80:20, 60:40, 40:60, and 20:80. Data were analyzed using the MIXED procedure of SAS (SAS Institute Inc.). The intensified management systems (F2, F3, and F4) increased the crude protein (CP) concentration of corn with no effects on starch concentration [32.1% dry matter (DM)] compared with the conventional system (F1). Decreasing cuts of grass from 5 to 3 reduced the CP concentration in the spring harvest (15.8% vs. 12.5% DM), and increased fiber concentration and reduced digestibility in the spring, summer, and fall harvests. A common concentrate was formulated for the conventional farmlet and then combined with the forages for each farmlet within each land allocation. Forages grown under intensified management to improve N capture increased the CP concentration of the diets. However, reducing the number of cuts of grass from 5 to 3, combined with the corn and relay crop to increase yield, reduced milk production across all land allocations. To complement the nutritive value of the forages grown under each management system and land allocation, the concentrates were reformulated, which reduced dietary CP, improved the indicators of N utilization (e.g., milk urea N and milk N efficiency), reduced N excretion, and improved milk yield with no differences among the farmlets. Increasing land allocated to corn supported higher milk yield at lower dietary CP concentrations (16.5% vs. 15.4% DM) with improved milk N efficiency and lower N excretion. Intensified agronomic management increased the CP of the combined forages decreasing the need for supplemental CP in the concentrate and could reduce the importation of feed N to the farm.

Aortic Intramural Hematoma in a Female Patient During Sexual Intercourse.

BACKGROUND Acute aortic syndrome (AAS) is a spectrum of severe life-threatening disease processes that are often initially encountered in the emergency department (ED) setting and require prompt recognition and treatment to prevent significant complications, including death. We describe an atypical presentation of aortic intramural hematoma in a female patient during sexual intercourse, a situation not previously described in the literature. CASE REPORT The patient was a 45-year-old woman who presented to the ED with a chief concern of chest pain. Just prior to the onset of her symptoms, the patient was having sexual intercourse with her husband, and during her orgasm she felt a "pop" in her chest with radiation to her back. The patient was diaphoretic and hypertensive on arrival, with a blood pressure of 220/140 mmHg. Computed tomography angiography of the chest was performed and showed an intramural hematoma (or thrombosed dissection) of the distal aortic arch and descending thoracic aorta. In the ED, the patient was started on intravenous antihypertensives, which were eventually switched to oral agents. Cardio-thoracic surgery staff was consulted and recommended medical management. As oral doses were increased, the intravenous antihypertensives were weaned, and the patient was eventually discharged home with scheduled outpatient follow-up. CONCLUSIONS Intramural aortic hematoma is a form of AAS with independent pathogenesis but similar progression, complications, and treatment as aortic dissection and thus demands efficient diagnosis and treatment. A high degree of suspicion, even in atypical situations, is paramount, as efficient recognition and treatment can be lifesaving.

Phosphorus characteristics of Canada-wide animal manures and implications for sustainable manure management with a cleaner environment.

Animal manure can be a serious environmental concern if improperly managed, particularly with regard to phosphorus (P). A good understanding on manure P chemistry is required for improving manure management in an environmentally sustainable manner. In the study, 102 representative manure samples collected from farms of major intensive livestock areas of Canada were sequentially fractionated with H2O, 0.5 M NaHCO3, 0.1 M NaOH, and 1.0 M HCl, respectively, for measuring inorganic (Pi) and organic P (Po). Across the manures, total P (TP) ranged from 3.71 to 17.3 g kg-1, with total Pi and available P (i.e., the sum of H2O-Pi and NaHCO3-Pi) accounting for 67.0-92.4 % and 35.6-67.3 % of TP, respectively. Composting reduced the percentages of available P and Po in TP, and meanwhile increased the percentages of moderately stable HCl-Pi. Compared to other P fractions, manure available P increased more rapidly with increases in TP; once manure TP reached 7.8-9.6 g kg-1, further TP increase enhanced transformation to more recalcitrant P (i.e., NaOH-Pi and HCl-Pi). Under Canadian conditions, manure application to meet the demand of crops for N would lead to P buildup in the soil at rates of 6.1-41.6 kg P ha-1 yr-1, increasing runoff P loss risk. Manure compost and poultry manure tend to cause rapid P buildup in the soil after land application and become a long-term P source for runoff losses. The results help to develop scientifically-sound manure-specific P management technologies which would enable farmers to achieve sustainable crop production with improved environment.

Syncope Due to a Ruptured Ectopic Pregnancy.

Audience: This simulation is intended for all levels of emergency medicine residents. Introduction: Syncope and near-syncope are very common presenting complaints to the emergency department.1 There are several causes of syncope ranging from benign to life threatening. It is imperative that the emergency physician is able to evaluate and treat patients with undifferentiated syncope even with limited information. Approximately half of syncope cases can be differentiated by the presentation and clinical context.1 In addition to a thorough history, an electrocardiogram (ECG) should be obtained on all patients presenting with syncope or near-syncope since it is non-invasive and cost effective in assessing cardiac causes of syncope. In this particular simulation, the cause of syncope is due to a hemorrhagic shock from a ruptured ectopic pregnancy. Educational Objectives: At the conclusion of this simulation, the learner will be able to:Review the initial management of syncopeUtilize laboratory and imaging techniques to diagnose a ruptured ectopic pregnancy.Demonstrate the ability to resuscitate and disposition an unstable ruptured ectopic pregnancy. Educational Methods: This simulation case was designed as a medium-to-high fidelity simulation scenario. It could also be altered and utilized as a practice oral board exam case. Research Methods: The quality of the simulation and educational content was evaluated by debriefing and verbal feedback that was obtained immediately after the case. Additionally, a survey was emailed to participants and observers of the case to provide qualitative feedback. Results: Post-simulation feedback from learners and observers was positive. Everyone present for the simulation felt that it was realistic and provided a unique opportunity to practice resuscitation skills. Discussion: Syncope and near-syncope are common presentations to the emergency department with multiple etiologies that range from cardiac, neurologic, neurocardiogenic, and orthostatic to unknown. It is crucial that we diagnose and treat life-threatening causes of syncope rapidly and with limited information. In this case, the cause of syncope due to a ruptured ectopic pregnancy should be rapidly diagnosed with a thorough history and exam, urine pregnancy test, and a bedside abdominal ultrasound. Once the urine pregnancy test was resulted, ectopic pregnancy was the top differential diagnosis for each learner that participated. Initially, most learners only performed a transabdominal pelvic ultrasound of the pelvis, which is normal in the case. One learner performed a rapid ultrasound for shock and hypotension (RUSH) exam and was able to find free fluid in the right upper quadrant. Overall, this case and the debriefing topics were effective for learners at all levels. Topics: Ectopic pregnancy, obstetrical emergencies, ultrasound, resuscitation.

A Case Report of Cardiac Tamponade.

Cardiac tamponade is a rare and life-threatening condition that can be caused by trauma and various medical conditions. Failure to recognize and repair it quickly could lead to significant morbidity or even death. This case demonstrates the electrocardiogram (ECG) findings of low voltage QRS and electrical alternans in cardiac tamponade. It also highlights the classic ultrasound (US) findings of pericardial effusion and right ventricular collapse during diastole in cardiac tamponade. Classic physical exam findings of cardiac tamponade include Beck's Triad (jugular venous distention, hypotension, and muffled heart sounds) and pulsus paradoxus. This patient only had jugular venous distention and pulsus paradoxus. The case is centered on a 52-year-old male who presented with shortness of breath, wheezing, and a productive cough with streaks of blood. A CT chest was performed which revealed a large pericardial effusion, right upper lobe lung mass, and bilateral pulmonary emboli. A bedside transthoracic echocardiogram was then performed which confirmed the large effusion as well as right ventricular collapse during diastole. Cardiothoracic surgery and interventional cardiology were consulted and both agreed to take the patient to the cardiac catheterization lab for percutaneous drainage of the effusion. Pericardiocentesis was performed and 1.7 liters of serosanguinous fluid was removed and a drain was left in place. He recovered well from the procedure and had an uneventful admission. After reviewing this case, learners should be able to recognize the diagnostic features and various causes of pericardial effusion and cardiac tamponade. Topics: Electrocardiography, echocardiography, cardiac tamponade.

Unsuspecting Dietary Factors in Hyperkalemia: A Case Report on Why History Matters.

INTRODUCTION: We present a case of hyperkalemia secondary to excessive dietary intake of hard caramel candies. CASE REPORT: An 88-year-old male who presented with acute abdominal pain and vomiting was found to have hyperkalemia of 6.9 milliequivalents per liter. He was stabilized, treated, and discharged the following day after resolution. The cause was identified as his daily consumption of 200 hard caramel candies. DISCUSSION: The patient had been consuming sugar-free candies, which induced a chronic diarrhea. This led to potassium wasting and augmentation of his home medications. When he transitioned to eating regular caramel candies, he retained too much potassium leading to his presentation. CONCLUSION: While often overlooked, dietary history is a crucial part of history-taking to ensure that the underlying cause for illness is discovered and addressed.

Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial.

BACKGROUND: Hospitalized patients frequently have urinary catheters inserted for inappropriate reasons. This can lead to urinary tract infections and other complications. OBJECTIVE: To assess whether stop orders for indwelling urinary catheters reduces the duration of inappropriate urinary catheterization and the incidence of urinary tract infections. DESIGN: A randomized controlled trial was conducted in three tertiary-care hospitals in Ontario, Canada. Patients with indwelling urinary catheters were randomized to prewritten orders for the removal of urinary catheters if specified criteria were not present or to usual care. PARTICIPANTS: Six hundred ninety-two hospitalized patients admitted to hospital with indwelling urinary catheters inserted for < or = 48 h. MEASUREMENTS: The main outcomes included days of inappropriate indwelling catheter use, total days of catheter use, frequency of urinary tract infection, and catheter reinsertions. RESULTS: There were fewer days of inappropriate and total urinary catheter use in the stop-order group than in the usual care group (difference -1.69 [95% CI -1.23 to -2.15], P < 0.001 and -1.34 days, [95% CI, -0.64 to -2.05 days], P < 0.001, respectively). Urinary tract infections occurred in 19.0% of the stop-order group and 20.2% of the usual care group, relative risk 0.94 (95% CI, 0.66 to 1.33), P = 0.71. Catheter reinsertion occurred in 8.6% of the stop-order group and 7.0% in the usual care group, relative risk 1.23 (95% CI, 0.72 to 2.11), P = 0.45. CONCLUSIONS: Stop orders for urinary catheterization safely reduced duration of inappropriate urinary catheterization in hospitalized patients but did not reduce urinary tract infections.