Orthopedic Articular and Periarticular Joint Infections.

Acute nontraumatic joint pain has an extensive differential. Emergency physicians must be adept at identifying limb and potentially life-threatening infection. Chief among these is septic arthritis. In addition to knowing how these joint infections typically present, clinicians need to be aware of host and pathogen factors that can lead to more insidious presentations and how these factors impact the interpretation of diagnostic tests.

Effects of vitamin D insufficiency on sepsis severity and risk of hospitalisation in emergency department patients: a cross-sectional study.

OBJECTIVE: To evaluate the association of 25-hydroxyvitamin D (25(OH)D) level on sepsis severity and risk of hospitalisation in emergency department (ED) septic patients when categorised as vitamin D insufficiency according to the level of 25(OH)D<30 ng/mL. DESIGN: Cross-sectional observational study. SETTING: A 900-bed academic tertiary hospital with an ED residency training programme in Bangkok, Thailand. PARTICIPANTS: An observational study of 101 ED septic patients aged ≥18 years was conducted between March 2015 and September 2015. OUTCOME MEASURES: The level of 25(OH)D was analysed and correlated with sepsis severity assessed by Acute Physiology Age Chronic Health Evaluation-II (APACHE-II) and Mortality in ED Sepsis (MEDS) scores, and the risk of hospitalisation. RESULTS: One hundred and one patients were enrolled, with an average age of 68±18 years, 56% female, APACHE-II score of 14±6, MEDS score of 8±5 and 25(OH)D level was 19±11 ng/mL. The prevalence of vitamin D insufficiency in our ED septic patients was 87% and the admission rate was 88%. A significant association between 25(OH)D level and sepsis severity scores was found, which was measured by APACHE-II and MEDS scores (-0.29; 95% CI -0.41 to -0.17, p<0.001 and -0.15; 95% CI -0.25 to -0.06, p=0.002, respectively). However, vitamin D insufficiency could not determine hospitalisation (OR=1.42; 95% CI 0.27 to 7.34; p=0.68 and OR=1.65; 95% CI 0.07 to 41.7; p=0.76 when adjusted by baseline covariates). CONCLUSIONS: The vitamin D insufficiency of septic patients in our ED was high and had a significant negative association with sepsis severity. However, vitamin D insufficiency status cannot predict the hospitalisation of septic patients who were admitted to the ED. Further research is needed to investigate the role of vitamin D supplementation in the ED in affecting sepsis severity. TRIAL REGISTRATION NUMBER: TCTR20151127001.

Perception of an Introductory Point-of-Care Ultrasound Course for Thai Medical Students on Emergency Medicine Rotation.

INTRODUCTION: Point-of-care ultrasonography (POCUS) is increasingly utilized in emergency departments (EDs) throughout Thailand. Although emergency medicine (EM) residents are trained in POCUS, Thai medical students receive limited training. An introductory POCUS course was implemented for medical students to prepare them for internships. OBJECTIVE: This study described the perception and use of POCUS by graduates of an introductory POCUS course. MATERIALS AND METHODS: Medical students who completed the POCUS course were surveyed during their intern year from 2012 to 2015. The survey collected demographic characteristics. The Likert Scale was used to assess POCUS practice patterns and perceptions of the course. RESULTS: There were 230 respondents (98% response rate). All thought that POCUS was important. Furthermore, 96% of respondents felt that the POCUS course meaningfully impacted their ability to deliver care. POCUS use was greatest for obstetrics/gynecology and trauma cases. Over half of respondents (55.2%) felt very confident with using extended-Focused Assessment with Sonography in Trauma. Most respondents (81.8%) were positively impacted by the course, and 61.7% were satisfied with the scope of the course. Recommendations for improvement included increasing the course length, the content, and the hands-on time for POCUS practice. CONCLUSION: Graduates positively perceived the course and felt it dramatically impacted their clinical practice as novice physicians. An introductory POCUS course should be incorporated into the medical school curriculum to prepare graduates for practice. Future goals include increasing the scope of POCUS practice to help guide interns and residents in emergency patient care such as lung ultrasound in COVID-19 or pneumonia patients and studying the impact this course has on patient outcomes.

How Clean Are You Really? A Simulation Study of Droplet Splash Using an Acrylic Box During Cardiopulmonary Resuscitation.

SUMMARY STATEMENT: In light of the COVID-19 pandemic, protocols to reduce risk of exposure to healthcare teams have been implemented. The use of an acrylic box during intubation and cardiopulmonary resuscitation has been adopted worldwide. A study was conducted to assess the effectiveness of an acrylic box in limiting contamination. The findings indicate that healthcare workers are still vulnerable to exposure despite the use of personal protective equipment (PPE) and an acrylic box. The causes of contamination were related to improper PPE donning and doffing and incomplete coverage by the acrylic box. Institutions should focus on ensuring proper donning and doffing of PPE and incorporating high-fidelity simulation training to prepare teams to resuscitate COVID-19 patients.

A Case of Splenic Laceration Presenting as a Delayed Complication of Colonoscopy.

BACKGROUND: Colonoscopy is a frequently performed medical procedure; complications associated with this procedure often present to the emergency department (ED). Splenic laceration is a rare but life-threatening complication of colonoscopy. We report the unique case of a patient with a splenic laceration who presented after a recent colonoscopy and had no history of trauma. CASE REPORT: A 52-year-old man presented to our ED with abdominal pain and lightheadedness the day after a routine colonoscopy. Ultrasound demonstrated hemoperitoneum, and contrast-enhanced computed tomography of the abdomen revealed a large hemoperitoneum with active contrast extravasation from the laceration of the superior pole of the spleen. After resuscitation, the patient was managed with an emergency splenectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Colonoscopy complications are frequently identified and managed in the ED. Splenic laceration should be on the differential for patients that present with abdominal pain or hypotension after colonoscopy. Splenic injury carries a high mortality risk, and prompt, accurate diagnosis can be lifesaving.

Massage-induced spinal epidural hematoma presenting with delayed paraplegia.

BACKGROUND: Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury. OBJECTIVE: We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia. CASE REPORT: A 20-year-old man presented with bilateral lower extremity weakness and numbness 3 h prior to presentation. 3 days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flow or AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma. CONCLUSION: Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome.

Perspectives of South American physicians hosting foreign rotators in emergency medicine.

BACKGROUND: Emergency Medicine (EM) is increasingly becoming an international field. The number of fellowships in International EM in the USA is growing along with opportunities to complete international health electives (IHEs) during residency training. The impact on host institutions, however, has not been adequately investigated. The objective of this study is to assess the experience of several South American hospitals hosting foreign EM residents completing IHEs. METHODS: Anonymous, semi-structured one-on-one interviews were conducted with physicians working in Emergency Departments in three hospitals in Lima, Peru and one hospital in Buenos Aires, Argentina. All participants reported previously working with EM foreign rotators. Interviews were analyzed qualitatively and coded for common themes. RESULTS: Three department chairs, six residents, and 15 attending physicians were interviewed (total = 24). After qualitative analysis of interviews, two broad theme categories emerged: Benefits and Challenges. Most commonly reported benefits were knowledge sharing about emergency medical systems (78%), medical knowledge transfer (58%), and long-term relationship formation (42%). Top challenges included rotator Spanish language proficiency (70%) lack of reciprocity (58%), and level of training and rotation length (25%). Spanish proficiency related directly to how involved rotators became in patient care (e.g., taking a history, participating in rounds) but was not completely prohibitive, as a majority of physicians interviewed felt comfortable speaking in English. Lack of reciprocity refers to the difficulty of sending host physicians abroad as well as failed attempts at building long-lasting relationships with foreign institutions. Lastly, 25% preferred rotators to stay for at least 1 month and rotate in the last year of EM residency. This latter preference increased knowledge transfer from rotator to host. CONCLUSIONS: Our research identified benefits and challenges of IHEs in Emergency Medicine from the perspective of physician hosts in several hospitals in South America. Our results suggest that IHEs function best when EM residents rotate later in residency training and when relationships are maintained and deepened among those involved including host physicians, rotators, and institutions. This leads to future rotators, project collaboration, research, and publications which not only benefit individuals involved but also the wider field of Emergency Medicine.

Pulmonary vein thrombosis associated with a large hiatal hernia.

BACKGROUND: Pulmonary vein thrombosis is a rare and potentially life-threatening condition. Reported cases of pulmonary vein thrombosis commonly occur as a complication of pulmonary surgery. There is a paucity of literature describing its clinical manifestations and non-operative causes. OBJECTIVE: We report the unique case of pulmonary vein thrombosis associated with a large hiatal hernia in a patient initially presenting with renal infarction. CASE REPORT: A 68-year-old man initially presented with increasing intensity of left lower quadrant pain. Contrast-enhanced computed tomography of the abdomen revealed left renal infarctions. Searching for an embolic source, further investigation revealed left inferior pulmonary vein thrombosis in the setting of venous compression in the lung tissue adjacent to a large hiatal hernia. CONCLUSION: Large hiatal hernias may be a nidus for pulmonary vein thrombosis, a potential source of left-sided emboli.

Lantus insulin overdose: a case report.

BACKGROUND: Insulin glargine is a relatively new medication in the treatment of diabetes mellitus, and there have only been six case reports of overdoses in the literature with this specific insulin. OBJECTIVES: We present a unique case of insulin glargine overdose that presented with persistent hypoglycemia and required prolonged in-hospital treatment. CASE REPORT: A 51-year-old woman with insulin-dependent diabetes and a history of suicide attempts by medication overdose presented to the Emergency Department the morning after she had self-administered 2700 units of her insulin glargine in an attempted suicide. She was treated with continuous intravenous dextrose infusion with liberal oral intake, and continued to have recurrent hypoglycemic episodes 96 h into her hospital stay. She was discharged on hospital day 5 after psychiatric clearance without any permanent complications. CONCLUSIONS: A single massive overdose of insulin glargine can present with prolonged hypoglycemia. Emergency physicians should have a low threshold for initiating continuous dextrose infusions and admitting these patients for frequent blood glucose and serum electrolyte monitoring, preferably in an intensive care setting.