Concurrent Pansinusitis and Orbital Cellulitis Complicated by Extensive Head and Neck Venous Thrombosis in an Unvaccinated Adolescent Patient with COVID-19: A Case Report.

BACKGROUND: Orbital cellulitis is an infrequent but serious infectious complication of rhinosinusitis, most commonly seen in the pediatric population. Extension into the cavernous sinus, leading to further infection and thrombosis, is a rare but life-threatening complication. Although COVID-19 has been linked to an increased risk of venous thromboembolism, most cases involve extremity deep venous thrombosis or pulmonary embolism; reports of intracranial or jugular system thrombosis are rare. CASE REPORT: We describe a case of a 17-year-old female patient with no significant medical history or thrombotic risk factors found to have orbital cellulitis and severe pansinusitis, complicated by multiple venous thromboses in the head and neck requiring emergent surgical intervention and pediatric intensive care admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Extensive head and neck venous thrombosis and intracranial abscesses are rare complications of pansinusitis and orbital cellulitis, and the thrombotic complications of COVID-19 are well documented. A delay in diagnosis and treatment can lead to potentially devastating consequences.

Implementation of a Military Emergency Department Influenza Vaccination Program: Lessons from Failure.

INTRODUCTION: Influenza infection in the United States results in hundreds of thousands of hospitalizations and 12,000 to 60,000 yearly deaths. Influenza season sees a sharp increase in emergency department (ED) patients nationwide, as primary care offices become overwhelmed. Because the ED is unique in its reach of underserved communities, ED vaccination programs can help maximize the number of people protected by vaccination. Influenza vaccination is one of the only vaccines that occurs yearly; therefore, successes with ED distribution of the influenza vaccine can potentially be translated into efforts of vaccinating the U.S. population more efficiently against other viral illnesses, such COVID-19. There has also not been a previous description in the literature of a vaccination program being used in a military setting. The original purpose of this study was to measure the effect of an ED vaccination program on our vaccine penetration and ED length of stay as well as to analyze the impact of provider education on vaccine uptake on vaccine refusal. METHODS: This was an observational, quality improvement project in the Wright-Patterson Medical Center Emergency Department evaluating an influenza vaccination program set to last from October 1, 2020 to April 1, 2021. Patients were to be surveyed to assess prior vaccination status, identify those at high risk for influenza complications, and to measure the effects of point-of-care education on vaccine acceptance. Separate measurements included average ED length of stay and the study's impact on how quickly the base population could be vaccinated. RESULTS: The effort was determined no longer feasible on November 20, 2020 because of the significant barriers. Although no data were gathered, we were able to glean important information that is vital in future efforts to implement ED-based vaccination programs. Reasons for program failure were multi-factorial, but were mainly attributed to rapid implementation, issues with Pyxis ordering and vaccine shipments, and vaccine storage capacity. The program also lacked a multidisciplinary implementation team of nurses and technicians, which could have better anticipated critical barriers. CONCLUSION: Influenza has caused multiple worldwide pandemics, contributed to countless deaths, and continues to be a challenge. ED-based influenza vaccination programs have been trialed to augment the primary care system in their effort to prevent deaths from influenza. The literature has shown that these programs are cost-effective and efficacious, but significant barriers have stunted their widespread utilization. Examining the rapid implementation and failure of this program highlights the importance of implementation models, process and barrier mapping, and proper operationalization. It is also the first such program that has been trialed in a military treatment facility. In consideration of the recent pandemic, successful ED-based vaccination programs can also offer a model for additional dissemination of other vaccines, such as the COVID-19 vaccine.

Emergency Department Presentation of Life-threatening Symptomatic Hyperkalemia From an Angiotensin Receptor Blocker in a Low-risk Individual.

Hyperkalemia is a common electrolyte abnormality with characteristic electrocardiogram changes. Both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) increase the risk of developing hyperkalemia. This case highlights a rare life-threatening episode of hyperkalemia in an individual whose only risk factor was an ARB. A 58-year-old female presented with sudden-onset chest pressure, light-headedness, and diaphoresis. Her initial electrocardiogram showed a nearly sinusoidal rhythm with a widened ventricular depolarization (QRS) and prolonged QT-interval (QTc). Life-threatening hyperkalemia of 9.1 mmol/L was confirmed with a rapid point-of-care electrolyte panel. She was rapidly treated with calcium, potassium-shifting and eliminating medications, and emergent hemodialysis. After stabilization, a thorough workup found that the patient's only risk factor for hyperkalemia was her use of an ARB. While both ARBs and ACEIs are commonly associated with mild hyperkalemia, life-threatening hyperkalemia is rare, particularly in patients without concomitant renal failure, diabetes mellitus, adrenal disease, or potassium-sparing diuretic use. However, this case illustrates that life-threatening hyperkalemia is possible in patients solely taking an ARB without prior significant risk factors. Despite normal renal function in an individual without heart failure or diabetes, this patient developed life-threatening hyperkalemia.

GLass intact Assures Safe cervical Spine protocol.

BACKGROUND: Selective cervical spine immobilization performed by Emergency Medical Services (EMS) is being utilized with increasing frequency. These protocols, although very sensitive, still include subjective data such as "mild cervical discomfort." The aim of this study is to create an objective clinical decision rule that would enhance the selective approach for cervical spine immobilization in patients aged 16-60 years. STUDY OBJECTIVE: It is hypothesized that, in a motor vehicle crash, the integrity of the involved vehicle's glass window and airbag status is an excellent objective measure for the amount of energy a vehicle occupant has experienced during the crash. GLass intact Assures Safe Spine (GLASS) is an easy and objective method for evaluation of the need for prehospital cervical spine immobilization. METHODS: A retrospective cohort study was performed with sample motor vehicle crash cases to evaluate the performance of the GLASS rule. The National Accident Sampling System-Crashworthiness Data System (NASS-CDS) was utilized to investigate tow-away motor vehicle crashes, including their glass damage characteristics and occupant injury outcomes, over an 11-year period (1998-2008). Sample occupant cases selected for this study were patients aged 16-60 years, who were belt-restrained front seat occupants involved in a crash with no airbag deployment, and no glass damage before the crash. RESULTS: A total of 14,191 occupants involved in motor vehicle crashes were evaluated in this analysis. The results showed that the sensitivity of the GLASS rule was 95.20% (95% confidence interval [CI] 91.45-98.95%), the specificity was 54.27% (95% CI 53.44-55.09%), and the negative predictive value was 99.92% (95% CI 99.86-99.98%). CONCLUSION: The GLASS rule presents the possibility of a novel, more objective tool for cervical spine clearance. Prospective evaluation is required to further evaluate the validity of this clinical decision rule.

Mal de debarquement presenting in the Emergency Department.

Mal de debarquement (MDD) is a common, benign, and self-limited syndrome suffered by many people after disembarkation from an oceangoing vessel. It is characterized by a continuing sensation of being on an unsteady pitching and rolling deck, even after a return to solid ground. Symptoms typically dissipate over several hours or days, but can linger for weeks. There is no effective treatment for MDD, no work-up is required, and patients can be reassured that the symptoms are transient. We present a case of MDD in a previously healthy 22-year-old male, and discuss the approach to MDD in the emergency department setting.