Acute Cardioembolic Stroke in the Setting of Subtherapeutic Anticoagulation.

Acute ischemic stroke is a sudden neurological deficit secondary to decreased or lack of blood flow (perfusion) due to a thrombus or an embolus. Embolic strokes are ischemic strokes that occur due to a distal clot that results in hypoperfusion upstream. Cardioembolic strokes are embolic strokes due to a cardiac origin. Almost a quarter of ischemic strokes are of cardioembolic etiology. Here, we present the case of an 83-year-old female presenting with right-side weakness and aphasia who arrived 45 minutes after symptom onset. Cardioembolic stroke symptoms, diagnosis, treatment, and risk factors are discussed.

Flash Burn of the Eyes Caused by High-Voltage Electrical Spark.

We present a rare case of corneal abrasion with mild eyelid epitheliopathy caused by a high-voltage electrical spark. The case includes emergency department evaluation and subsequent management at the burn center with ophthalmology. The prognosis, in this case, is good, however, the potential severity of high-voltage electrical injuries can be much worse. Prevention strategies for occupational electrical injuries are discussed with an emphasis on proper personal protective equipment (PPE).

What Do Spanish Speakers Think of the Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas (AHORA) Stroke Tool?

AHORA (Andar, Hablar, Ojos, Rostro, Ambos Brazos o Piernas) is a Spanish language tool to identify stroke symptoms. A survey of 300 primarily Spanish-speaking, non-medical professionals was conducted to assess the acceptance of the tool, specifically about ease of understanding and ability to implement it. The overwhelming majority of respondents reacted very positively to the tool, finding it quite easy to learn, teach, and understand. Respondent feedback, pitfalls, and questions for further research are presented.

Stevens Johnson Syndrome Initiated by an Adverse Reaction to Trimethoprim-Sulfamethoxazole.

The authors present a case of a 54-year-old male who presented to the ED with Stevens Johnson syndrome (SJS) beginning on his upper lips, then spreading to his glans penis, airway, and buttocks. After using trimethoprim-sulfamethoxazole (TMP-SMX) to treat a pilonidal cyst diagnosed seven days prior to presentation, the patient began to have desquamating lesions on his upper and lower lips. Subsequently, he noticed desquamation on the glans penis and then between his buttocks. Before being referred to dermatology, he was treated with a high dosage of corticosteroids.

Acute Myasthenia Crisis: A Critical Emergency Department Differential.

Myasthenia gravis (MG) is the most common autoimmune disorder of the neuromuscular junction (NMJ). It is caused by autoantibodies blocking acetylcholine receptors (AChRs) or structural receptors of the NMJ: agrin, LRP4, and MuSK. These antibodies can block, change, or destroy AChRs or structural proteins of the NMJ, preventing the binding of ACh and therefore, muscle contractions. This molecular dysfunction can manifest as any of the following symptoms: ptosis, diplopia, bulbar dysfunction, or impaired vision in bright light. Symptoms fluctuate in severity throughout the day and with prolonged use of respective muscles. Typical treatment for mild cases is acetylcholinesterase inhibition combined with an immunosuppressor. Myasthenia crisis results from the exacerbation of the aforementioned symptoms and requires intubation for respiratory support. Intensive care along with intensified immunosuppressive treatments and constant monitoring are recommended. We present the case of a 76-year-old man arriving to the emergency department (ED) with symptoms of fatigue and dysphagia, diagnosed as acute myasthenia crisis. Here, we highlight the symptoms of MG, acute myasthenia crisis, and the critical measures that need to be taken.

Serum Procalcitonin Level Is Associated with Positive Blood Cultures, In-hospital Mortality, and Septic Shock in Emergency Department Sepsis Patients.

This study examines the accuracy of initial and subsequent serum procalcitonin (PCT) levels in predicting positive blood cultures, in-hospital mortality, and development of septic shock in emergency department (ED) patients with severe sepsis. This study includes all patients who presented to our ED with an admission diagnosis of severe sepsis over a period of nine months. The median initial PCT was 0.58 ng/mL, interquartile range (IQR) 0.16-5.39. The median subsequent serum PCT was 2.1 ng/mL, with an IQR of 0.3-11.1. The PCT trend over the initial three hours increased in 67% of the study population. Blood cultures were positive in 38% of the cohort. The median maximum PCT in those with a negative blood culture was 1.06 ng/mL compared to 4.19 ng/mL in those with a positive blood culture (p=0.0116). Serum PCT levels >2.0 ng/mL display significant correlation with positive blood cultures, in-hospital mortality, and development of septic shock and as such may serve as a biomarker for more serious infections.

Cardiac Arrest Following Treatment With Diltiazem for Atrial Fibrillation With Rapid Ventricular Response.

We present the case of a 43-year-old man with a history of atrial fibrillation and poor medical compliance who presented to the emergency department with palpitations for three hours. Electrocardiogram (ECG) revealed atrial fibrillation with rapid ventricular response at 119 beats per minute. Following administration of diltiazem 10 mg IV, the patient became bradycardic with a rate of 30 beats per minute and complete atrioventricular node block. A subsequent ECG revealed asystole, and the patient became unresponsive. Chest compressions were administered, and the rhythm changed to ventricular tachycardia. There was spontaneous return of circulation without any further intervention. The patient eventually converted to sinus rhythm and was started on anticoagulation to prevent a thrombotic event. He was discharged the next day with apixaban and propafenone.

Large Vessel Occlusion Identification Through Prehospital Administration of Stroke Scales: A County-wide Emergency Medical Services Prospective Research Protocol.

There is yet insufficient research on prehospital stroke scales, especially for identifying large vessel occlusions and severe strokes. When multiple stroke centers are available, determining which patients should go directly to a comprehensive stroke center (CSC) is critical. Delay in care transporting to a hospital not capable of treating hemorrhagic strokes and large vessel occlusions (LVOs) can be devastating. The failure rate for tissue plasminogen activator (tPA), a clot-busting drug commonly used to treat ischemic stroke that can be administered at primary stroke centers, is up to 90% for large vessel occlusions (LVOs). However, these patients can benefit from mechanical intervention, performed only at CSCs. Hemorrhagic strokes often result from ruptured aneurysms, which can benefit from coiling and clipping, procedures also typically only available at CSCs. In order to analyze the effectiveness of certain prehospital stroke scales, our county's emergency medical services (EMS) system designed and implemented the LVO identification through prehospital administration of stroke scales (LIT-PASS), a prospective cohort study. Our study has three phases, each phase testing a certain combination of prehospital stroke scales. The protocol, including training for every paramedic, was started in 2015, and data collection began in 2016. In Phase 1, we tested the Los Angeles motor scale (LAMS) alone from January 2016 to November 2018. In Phase 2, we administered both the LAMS and the vision, aphasia, neglect (VAN) test from December 2018 to May 2019. Phase 3 began in June 2019 and uses the balance, eyes, face, arm, speech, terrible headache/time to call 911 (BE-FAST) test as a scale, allotting one point for each category. While the "time to call 911" aspect is not part of the scale, it is included in the name for mnemonic reasons. We chose these scales because of the symptoms they cover and due to their simplicity. Phase 1 assesses only motor symptoms, Phase 2 assesses motor and additional cortical symptoms, and Phase 3 evaluates a scale that combines both components and whose acronym is a useful mnemonic for paramedics. Each paramedic in our county's system was given a one-hour training session on the scales each year in Phase 1 and once prior to the beginning of Phase 2 and Phase 3. Paramedics were not allowed to respond to a stroke call unless they had completed the training. This is done to avoid bias in which patients are studied, ensuring that all stroke patients are subject to our county's stroke protocol. Data were de-identified and analyzed to evaluate the effectiveness of four things: in Phases 1 and 2, the LAMS alone; in Phase 2, the VAN test alone, as well as in combination with the LAMS; and in Phase 3, the effectiveness of the BE-FAST scale.

Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival.

AIM: To evaluate the frequency of neurologically-intact survival (SURV) following pediatric out-of-hospital cardiac arrest (POHCA) when comparing traditional early evacuation strategies to those emphasizing resuscitation efforts being performed immediately on-scene. METHODS: Before 2014, emergency medical services (EMS) crews in a county-wide EMS agency provided limited treatment for POHCA on-scene and rapidly transported patients to appropriate hospitals. After 2014, training strongly concentrated upon EMS provider comfort levels with on-scene resuscitation efforts including methods to expedite protocols on-site and control positive-pressure ventilation. Frequency of SURV (hospital discharge) was compared for the two years prior to initiating the immediate on-scene care strategy to the ensuing two years following implementation. RESULTS: Between 01/01/2012 and 12/31/2015, 94 children experienced POHCA. There were no significant differences before and after the on-scene focus in terms of age, sex, etiology, presenting electrocardiograph, drug infusions or bystander-performed cardiopulmonary resuscitation and total scene times actually remained similar (14.3 vs. 17.67 minutes). SURV increased significantly upon implementation of the immediate on-scene management strategy and was sustained over the next two years (0.0% to 23%; p = 0.0013). Though statistically-indeterminate in this analysis, the improvement was associated with a shorter mean time to epinephrine administration among resuscitated patients (16.6 vs. 7.65 minutes). CONCLUSION: Facilitating immediate on-scene management of POHCA can result in improvements in life-saving. Although a historically-controlled evaluation, the compelling appearance of neurologically-intact survivors was immediate and sustained. Targeted training, more efficient, physiologically-driven procedures, and trusted encouragement from supervisors, likely played the most significant roles and not necessarily extended scene times.