Post-abortion Complications: A Narrative Review for Emergency Clinicians.

An abortion is a procedure defined by termination of pregnancy, most commonly performed in the first or second trimester. There are several means of classification, but the most important includes whether the abortion was maternally "safe" (performed in a safe, clean environment with experienced providers and no legal restrictions) or "unsafe" (performed with hazardous materials and techniques, by person without the needed skills, or in an environment where minimal medical standards are not met). Complication rates depend on the procedure type, gestational age, patient comorbidities, clinician experience, and most importantly, whether the abortion is safe or unsafe. Safe abortions have significantly lower complication rates compared to unsafe abortions. Complications include bleeding, retained products of conception, retained cervical dilator, uterine perforation, amniotic fluid embolism, misoprostol toxicity, and endometritis. Mortality rates for safe abortions are less than 0.2%, compared to unsafe abortion rates that range between 4.7-13.2%. History and physical examination are integral components in recognizing complications of safe and unsafe abortions, with management dependent upon the diagnosis. This narrative review provides a focused overview of post-abortion complications for emergency clinicians.

Local anesthetic systemic toxicity: A narrative review for emergency clinicians.

INTRODUCTION: Emergency clinicians utilize local anesthetics for a variety of procedures in the emergency department (ED) setting. Local anesthetic systemic toxicity (LAST) is a potentially deadly complication. OBJECTIVE: This narrative review provides emergency clinicians with the most current evidence regarding the pathophysiology, evaluation, and management of patients with LAST. DISCUSSION: LAST is an uncommon but potentially life-threatening complication of local anesthetic use that may be encountered in the ED. Patients at extremes of age or with organ dysfunction are at higher risk. Inadvertent intra-arterial or intravenous injection, as well as repeated doses and higher doses of local anesthetics are associated with greater risk of developing LAST. Neurologic and cardiovascular manifestations can occur. Early recognition and intervention, including supportive care and intravenous lipid emulsion 20%, are the mainstays of treatment. Using ultrasound guidance, aspirating prior to injection, and utilizing the minimal local anesthetic dose needed are techniques that can reduce the risk of LAST. CONCLUSIONS: This focused review provides an update for the emergency clinician to manage patients with LAST.

High risk and low prevalence diseases: Spinal epidural abscess.

INTRODUCTION: Spinal epidural abscess (SEA) is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of SEA, including presentation, initial evaluation, and management in the emergency department (ED) based on current evidence. DISCUSSION: SEA is a suppurative infection and infectious disease emergency that may result in significant morbidity and even mortality. It is a challenging diagnosis due to its range of risk factors and variety of presentations with up to 90% of patients misdiagnosed on their first ED visit. Factors associated with increased risk of SEA include immunocompromise, bacteremia, contiguous infection (e.g., psoas muscle abscess, osteomyelitis, skin infection), and spinal instrumentation. However, the absence of risk factors cannot be used to exclude SEA. The classic triad of back pain, fever, and neurologic deficit occurs in less than 8% of cases, though back pain is a common presenting symptom. Up to half of patients experience a neurologic abnormality, but fever is absent in 50%. Laboratory assessment may assist with inflammatory markers elevated in the majority of cases. Diagnosis includes magnetic resonance imaging with and without contrast and blood cultures, and management includes spinal specialist consultation and antibiotic therapy. CONCLUSIONS: An understanding of SEA can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Professional development during a pandemic: a live virtual conference for emergency medicine chief residents.

Limited professional development training exists for chief residents. The available training uses in-person lectures and workshops at annual national conferences. The COVID-19 pandemic prevented most in-person gatherings in 2020, including pivotal onboarding and training events for new chief residents. However, for the last five years, Academic Life in Emergency Medicine's Chief Resident Incubator conducted year-long remote training programs, creating virtual communities of practice for chief residents in emergency medicine (EM). As prior leaders and alumni from the Incubator, we sought to respond to the limitations presented by the pandemic and create an onboarding event to provide foundational knowledge for incoming chief residents. We developed a half-day virtual conference, whereupon 219 EM chief residents enrolled. An effective professional development experience is feasible and scalable using online videoconferencing technologies, especially if constructed with content expertise, psychological safety, and production design in mind.

RéSUMé: Il existe une formation de développement professionnel limitée pour les résidents en chef. La formation disponible utilise des conférences et des ateliers en personne lors de conférences nationales annuelles. La pandémie de COVID-19 a empêché la plupart des rassemblements en personne en 2020, y compris des activités d'intégration et de formation essentielles pour les nouveaux résidents en chef. Cependant, au cours des cinq dernières années, l'incubateur des résidents en chef de Academic Life in Emergency Medicine a organisé des programmes de formation à distance d'un an, créant ainsi des communautés de pratique virtuelles pour les résidents en chef en médecine d'urgence (MU). En tant qu'anciens dirigeants et anciens de l'incubateur, nous avons cherché à répondre aux limites présentées par la pandémie et à créer un événement d'intégration pour fournir des connaissances fondamentales aux nouveaux résidents en chef. Nous avons mis au point une conférence virtuelle d'une demi-journée, à laquelle 219 résidents en chef de MU se sont inscrits. Une expérience de développement professionnel efficace est réalisable et évolutive grâce aux technologies de vidéoconférence en ligne, surtout si elle est construite en tenant compte de l'expertise du contenu, de la sécurité psychologique et de la conception de la production.

Use of Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement and Evaluate for Postprocedural Complications.

BACKGROUND: Central venous catheter (CVC) placement is commonly performed in the emergency department (ED), but traditional confirmation of placement includes chest radiograph. OBJECTIVE: This manuscript details the use of point-of-care ultrasound (POCUS) to confirm placement of a CVC and evaluate for postprocedural complications. DISCUSSION: CVC access in the ED setting is an important procedure. Traditional confirmation includes chest radiograph. POCUS is a rapid, inexpensive, and accurate modality to confirm CVC placement and evaluate for postprocedural complications. POCUS after CVC can evaluate lung sliding for pneumothorax and the internal jugular vein for misdirected CVC. A bubble study with POCUS visualizing agitated saline microbubbles within the right heart can confirm venous placement. CONCLUSIONS: POCUS can rapidly and reliably confirm CVC placement, as well as evaluate for postprocedural complications. Knowledge of this technique can assist emergency clinicians.

Cryptococcal meningitis: a review for emergency clinicians.

INTRODUCTION: Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM. DISCUSSION: This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS). CONCLUSIONS: CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.

Electrocardiographic manifestations of COVID-19.

INTRODUCTION: Coronavirus disease of 2019 (COVID-19) is a lower respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This disease can impact the cardiovascular system and lead to abnormal electrocardiographic (ECG) findings. Emergency clinicians must be aware of the ECG manifestations of COVID-19. OBJECTIVE: This narrative review outlines the pathophysiology and electrocardiographic findings associated with COVID-19. DISCUSSION: COVID-19 is a potentially critical illness associated with a variety of ECG abnormalities, with up to 90% of critically ill patients demonstrating at least one abnormality. The ECG abnormalities in COVID-19 may be due to cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury. While sinus tachycardia is the most common abnormality, others include supraventricular tachycardias such as atrial fibrillation or flutter, ventricular arrhythmias such as ventricular tachycardia or fibrillation, various bradycardias, interval and axis changes, and ST segment and T wave changes. Several ECG presentations are associated with poor outcome, including atrial fibrillation, QT interval prolongation, ST segment and T wave changes, and ventricular tachycardia/fibrillation. CONCLUSIONS: This review summarizes the relevant ECG findings associated with COVID-19. Knowledge of these findings in COVID-19-related electrocardiographic presentations may assist emergency clinicians in the evaluation and management of potentially infected and infected patients.

Plastic Surgery Complications: A Review for Emergency Clinicians.

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

Fournier Gangrene in the Emergency Department: Diagnostic Dilemmas, Treatments and Current Perspectives.

Fournier gangrene (FG) is a rare and life-threatening urosurgical emergency characterized most often by a polymicrobial infection of the perineal, genital, or perianal region. FG has an increased incidence in male patients, patients with alcoholism, and patients with immunocompromise including human immunodeficiency virus (HIV) and uncontrolled diabetes. FG often begins as a simple abscess or cellulitis with progression to necrotizing soft tissue infection (NSTI). Delays in diagnosis and treatment confer high mortality. Early recognition and high clinical suspicion are important in making a timely diagnosis, as early manifestations are often subtle. The most significant modifiable risk factor associated with NSTI mortality is delay to surgical intervention. Coordination of both inpatient medical and surgical teams to implement appropriate therapy is vital to successful outcomes. The emergency medicine clinician must be vigilant for this condition and be aware of risk factors, prognostic indicators, and proper treatment protocols to recognize FG early and initiate appropriate management. The objective of this review is to provide updated and relevant information regarding recognition, diagnosis, and management of FG for the emergency medicine provider.

Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS.

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases. OBJECTIVE: This narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation. DISCUSSION: In severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4-8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H2O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause. CONCLUSIONS: This review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.

Acute chloroquine and hydroxychloroquine toxicity: A review for emergency clinicians.

BACKGROUND: Acute chloroquine and hydroxychloroquine toxicity is characterized by a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias and is associated with significant morbidity and mortality. OBJECTIVE: This review describes acute chloroquine and hydroxychloroquine toxicity, outlines the complex pathophysiologic derangements, and addresses the emergency department (ED) management of this patient population. DISCUSSION: Chloroquine and hydroxychloroquine are aminoquinoline derivatives widely used in the treatment of rheumatologic diseases including systemic lupus erythematosus and rheumatoid arthritis as well as for malaria prophylaxis. In early 2020, anecdotal reports and preliminary data suggested utility of hydroxychloroquine in attenuating viral loads and symptoms in patients with SARS-CoV-2 infection. Aminoquinoline drugs pose unique and significant toxicological risks, both during their intended use as well as in unsupervised settings by laypersons. The therapeutic range for chloroquine is narrow. Acute severe toxicity is associated with 10-30% mortality owing to a combination of direct cardiovascular effects and electrolyte derangements with resultant dysrhythmias. Treatment in the ED is focused on decontamination, stabilization of cardiac dysrhythmias, hemodynamic support, electrolyte correction, and seizure prevention. CONCLUSIONS: An understanding of the pathophysiology of acute chloroquine and hydroxychloroquine toxicity and available emergency treatments can assist emergency clinicians in reducing the immediate morbidity and mortality associated with this disease.

COVID-19 respiratory support in the emergency department setting.

INTRODUCTION: Severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2), which causes the coronavirus disease 2019 (COVID-19), may result in severe complications, multiorgan dysfunction, acute respiratory failure, and death. SARS-CoV-2 is highly contagious and places healthcare workers at significant risk, especially during aerosol-generating procedures, including airway management. OBJECTIVE: This narrative review outlines the underlying respiratory pathophysiology of patients with COVID-19 and discusses approaches to airway management in the emergency department (ED) based on current literature. DISCUSSION: Patients presenting with SARS-CoV-2 infection are at high risk for acute respiratory failure requiring airway management. Among hospitalized patients, 10-20% require intensive care unit admission, and 3-10% require intubation and mechanical ventilation. While providing respiratory support for these patients, proper infection control measures, including adherence to personal protective equipment policies, are necessary to prevent nosocomial transmission to healthcare workers. A structured approach to respiratory failure in these patients includes the use of exogenous oxygen via nasal cannula or non-rebreather, as well as titrated high-flow nasal cannula and non-invasive ventilation. This review offers several guiding principles and resources designed to be adapted in conjunction with local workplace policies for patients requiring respiratory support. CONCLUSIONS: While the fundamental principles of acute respiratory failure management are similar between COVID-19 and non-COVID-19 patients, there are some notable differences, including a focus on provider safety. This review provides an approach to airway management and respiratory support in the patient with COVID-19.

COVID-19 cardiac arrest management: A review for emergency clinicians.

INTRODUCTION: A great deal of literature has recently discussed the evaluation and management of the coronavirus disease of 2019 (COVID-19) patient in the emergency department (ED) setting, but there remains a dearth of literature providing guidance on cardiac arrest management in this population. OBJECTIVE: This narrative review outlines the underlying pathophysiology of patients with COVID-19 and discusses approaches to cardiac arrest management in the ED based on the current literature as well as extrapolations from experience with other pathogens. DISCUSSION: Patients with COVID-19 may experience cardiovascular manifestations that place them at risk for acute myocardial injury, arrhythmias, and cardiac arrest. The mortality for these critically ill patients is high and increases with age and comorbidities. While providing resuscitative interventions and performing procedures on these patients, healthcare providers must adhere to strict infection control measures and prioritize their own safety through the appropriate use of personal protective equipment. A novel approach must be implemented in combination with national guidelines. The changes in these guidelines emphasize early placement of an advanced airway to limit nosocomial viral transmission and encourage healthcare providers to determine the effectiveness of their efforts prior to placing staff at risk for exposure. CONCLUSIONS: While treatment priorities and goals are identical to pre-pandemic approaches, the management of COVID-19 patients in cardiac arrest has distinct differences from cardiac arrest patients without COVID-19. We provide a review of the current literature on the changes in cardiac arrest management as well as details outlining team composition.

Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review.

Right-to-left pulmonary and cardiac shunts (RLS) are important causes of refractory hypoxia in the critically-ill perioperative patient. Using a point-of-care ultrasound (POCUS) agitated saline bubble study for an early diagnosis allows patients with clinically significant RLSs to receive expedited therapy. This narrative review discusses the principles of agitated saline ultrasonography as well as the role of POCUS in detecting the most common RLS types seen in the intensive care unit, including patent foramen ovale, atrial septal defects, and pulmonary arterio-venous malformations. An illustrated discussion of the procedure, as well as shunt-enhancing maneuvers (Valsalva or lung recruitment maneuver with subsequent rapid release) is provided. With the wide dissemination of bedside ultrasound within the perioperative and critical care arena, POCUS practitioners should be knowledgeable of the potential pitfalls leading to both false-positive and false-negative studies. False-positive studies may be due to congenital abnormalities, mischaracterization of intrapulmonary shunts as intracardiac shunts (and vice versa), or evidence of the Valsalva effect. False negatives are typically due to respiratory-phasic variation, performing an inadequate shunt-enhancing maneuver, inadequate injection of agitated saline, or pathophysiologic states of elevated left atrial pressure. Finally, alternative POCUS methods for determining presence of an RLS in patients with poor echocardiographic windows are discussed, with a focus on pulsed-wave Doppler interrogation of arterial signals.

RéSUMé: Les shunts pulmonaires et cardiaques de droite à-gauche sont d'importantes causes d'hypoxie réfractaire chez le patient périopératoire en état critique. En réalisant un test aux bulles sous échographie au chevet, un diagnostic rapide de shunt de droite à-gauche peut être posé, favorisant le traitement rapide des patients présentant un shunt de droite à-gauche significatif d'un point de vue clinique. Ce compte rendu narratif présente les principes de l'échographie avec test aux bulles ainsi que le rôle de l'échographie au chevet pour détecter les types les plus répandus de shunts de droite à-gauche à l'unité de soins intensifs, notamment les communications interauriculaires, les foramens ovales perméables et les malformations artérioveineuses pulmonaires. Nous présentons également une discussion illustrée de l'intervention, ainsi que des manœuvres augmentant le shunt (manœuvre de Valsalva ou de recrutement pulmonaire avec cessation rapide subséquente). Étant donné l'utilisation répandue de l'échographie dans le domaine des soins périopératoires et critiques, les praticiens de l'échographie au chevet devraient être conscients des écueils potentiels menant à des résultats faux positifs ou faux négatifs. Les résultats faux positifs peuvent être dus à des anomalies congénitales, à la caractérisation erronée de shunts intrapulmonaires en tant que shunts intracardiaques (et vice versa) ou à l'efficacité de l'effet Valsalva. Les résultats faux négatifs sont fréquemment dus à des variations des phases respiratoires, à la réalisation d'une manœuvre inadéquate d'amélioration du shunt, à l'injection inadéquate de solution saline agitée, ou à des états physiopathologiques de pression auriculaire gauche élevée. Enfin, les méthodes alternatives d'échographie au chevet visant à déterminer la présence d'un shunt de droite à-gauche chez les patients présentant des fenêtres échocardiographiques sous-optimales sont discutées, avec une emphase sur l'interrogation des signaux artériels par Doppler pulsé.

Necrotizing Soft Tissue Infection and Perforated Viscus After Suction-Assisted Lipectomy.

Suction-assisted lipectomy (SAL) is a commonly performed cosmetic surgery in the United States and has been steadily increasing in popularity over the past few years. As more of these surgeries are performed, several rare but life-threatening complications are being recognized, including necrotizing soft tissue infections (NSTIs). NSTIs require rapid surgical intervention but can be challenging to diagnose, as skin manifestations may be difficult to differentiate from normal post-SAL changes. We present a case of a 44-year-old female who presented with signs of septic shock after SAL of her abdomen and back. She was ultimately found to have an NSTI of her abdominal wall, likely due to perforated viscus that occurred as a complication of her procedure. This case demonstrates the significance of recognizing NSTIs as a potential complication of SAL in ill-appearing patients with non-specific symptoms and septic shock.

Spontaneous Splenic Artery Pseudoaneurysm Rupture Causing Hemorrhagic Shock.

Splenic artery pseudoaneurysm (SAP) is an uncommon etiology of acute abdominal pain, requiring a high degree of clinical suspicion to diagnose in a timely manner. There are currently no reports of spontaneous SAP ruptures in the emergency medicine literature. We report a case of a man who presented with acute abdominal pain secondary to an SAP. A computed tomography angiography scan of the abdomen revealed a ruptured SAP with hemoperitoneum. He successfully underwent emergency laparotomy and surgical ligation of his SAP with splenectomy. SAP rupture remains an under-recognized etiology of abdominal pain, even though it is the most frequent type of visceral pseudoaneurysm. Our case herein reinforces the importance of a broad list of differential diagnoses in the patient with acute abdominal pain, as well as the importance of the emergency physician in identifying an emergent condition and then directing the initial stabilization, resuscitation, and management.