Shone Complex: A Case Report of Congenital Heart Disease Detected Using Point-of-care Ultrasound.

INTRODUCTION: Undiagnosed congenital heart disease and management of pediatric cardiogenic shock presents a diagnostic challenge for the emergency clinician. These diagnoses are rare and require a high index of suspicion given the overlap with more common pediatric pathology. Point-of-care ultrasound can assist in differentiating these presentations. We present a case of neonatal cardiogenic shock secondary to a previously undiagnosed congenital heart disease, specifically Shone complex, detected using point-of-care ultrasound. CASE REPORT: A six-week-old female presented with severe respiratory distress and was found to be in cardiogenic shock secondary to a previously undiagnosed congenital heart defect. CONCLUSION: Initial diagnosis of congenital heart disease is uncommon in the emergency department, but it should be recognized by clinicians given the high associated morbidity and mortality. Point-of-care ultrasound is a powerful tool to assist in evaluating for cardiac abnormalities as an etiology for undifferentiated shock in the pediatric population.

The Golden Opportunity: Multidisciplinary Simulation Training Improves Trauma Team Efficiency.

OBJECTIVE: Every trauma patient has a golden hour, and resuscitation efficiency within that hour has large implications for patients. We instituted simulation based trauma resuscitation training with the hypothesis that it would improve trauma team efficiency. METHODS: Five simulation training sessions were conducted with immediate debriefing. Metrics collected in actual trauma resuscitations before and after simulation training included time of primary and secondary surveys and time to computed tomography (CT) scan. Study participants were from multidisciplinary specialties involved in trauma resuscitations as well as former trauma patients from the Trauma Survivors Network. RESULTS: Seventy-three patients undergoing trauma resuscitations were screened and 67 patients were included. Time to CT scan and secondary survey completion were significantly reduced in actual trauma patient activations following implementation of the curriculum (reduction of 23 to 16 minutes for CT scan p < 0.05, and reduction from 14 to 6 minutes for secondary survey, p < 0.05). Time to primary survey completion did not change (5 minutes). CONCLUSIONS: Multidisciplinary simulation training was associated with improved trauma team efficiency in the form of reduced assessment time. As emergency department length of stay is an independent predictor of hospital mortality following trauma activation, team-based simulation training has the potential to improve patient outcomes. Multidisciplinary involvement was a key factor, and Trauma Survivors Network involvement brought credibility from the patient perspective.

Intern Passport: Orienting New Travelers to the Emergency Department.

The objective of the Intern Passport (IP) curriculum was to implement a structured orientation for incoming interns that effectively defined and distinguished various personnel and assets within the emergency department (ED). The method of training was an on-the-job orientation that required interns to obtain "stamps" (signatures) on their passports during visits to eight "countries" (specialists) within the ED. Topics covered during the visit included introductions, tasks and capabilities, expectations, and pearls and pitfalls. Interns obtained stamps after spending 30-minute orientation visits with each country during the first four-week rotation of internship. The ED countries visited were Adult Nursing, Pediatric Nursing, Orthopedics Technician, Respiratory Therapy, Pharmacy, Psychiatry, Observation, and Radiology. Effectiveness was assessed by participant completion of an optional anonymous retrospective survey. The IP was a beneficial addition to our intern orientation curriculum. It effectively defined and distinguished various personnel and assets within the ED.

Toxic Alcohol Ingestion/Methanol Ingestion.

Introduction: Methanol poisoning is an uncommon life-threatening ingestion associated with significant morbidity and requires prompt diagnosis and management for the best possible outcome. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an anion gap metabolic acidosis, narrow the differential based on reasoning, and empirically initiate management. Methods: The simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. First-year residents managed the case as a team of two. Second- and third-year residents and fellows managed the case alone. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, provide stabilization of life threats, and initiate specific interventions based on a presumptive diagnosis. The simulation was followed by a 20-minute facilitated debrief session that reviewed key learning points and learner performance based on an evaluation checklist. Results: Residents completed a six-question, 5-point Likert-scale postparticipation questionnaire. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap. Discussion: This simulation experience successfully exposed residents to the uncommon presentation of methanol poisoning. The simulation experience effectively closed the identified educational gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.

Chronic Salicylate Toxicity Simulation.

Introduction: Chronic salicylate toxicity is an uncommon, potentially life-threatening poisoning that requires high clinical suspicion in order to make the diagnosis. We created a simulation case that challenges learners to analyze case information, construct a differential diagnosis of an elevated anion gap metabolic acidosis with respiratory alkalosis, and initiate treatment for this toxicity. Methods: The simulation case was designed for emergency medicine residents and pediatric emergency medicine fellows. The activity began with a brief overview of the monitors, equipment, and simulation experience. For interns, a team of two learners comanaged the case; for senior learners, the case was managed solo. The learners had 15 minutes to complete a focused history and physical exam, request and interpret labs and studies, and initiate specific treatments. The simulation was followed by a 15-minute facilitated debrief session that included an overview of key learning points and learner performance based on an evaluation checklist. Results: Residents completed a postparticipation questionnaire consisting of six questions rated on a 5-point Likert scale. Overall, residents reported a high degree of satisfaction with the simulation experience. The case and debrief were effective in meeting the educational objectives and proved to be an effective modality to fill this educational gap. Discussion: This simulation exercise was effective in showing residents the uncommon presentation of chronic salicylate toxicity. Learners reported increased confidence in recognizing and managing this ingestion. The simulation experience closed an identified education gap and provided an experiential learning opportunity that accomplished the targeted learning objectives.

Bedside ultrasound for the detection of soft tissue foreign bodies: a cadaveric study.

The objective of this study was to evaluate the sensitivity and specificity of bedside ultrasound, as performed by emergency physicians with typical equipment, in detecting small, soft tissue foreign bodies, using a cadaveric model. This was a prospective study, using 6 unembalmed human cadavers and 6 ultrasound-credentialed, emergency medicine residency-trained physicians as sonographers. Incisions were made in 150 total sites of the extremities and each site was randomly assigned one of five groups: wood, metal, plastic, glass, or no foreign body. All foreign bodies were 2.5 mm3 in total volume or less, no longer than 5 mm in any dimension, and inserted to a depth of up to 3 cm. Ultrasound was performed with a SonoSite TITAN (SonoSite, Inc., Bothell, WA) ultrasound system using a L38/10-5 broadband linear array transducer. Sonographers were blinded to the number, type, and location of foreign bodies. A total of 900 ultrasound examinations were recorded. Overall sensitivity of ultrasound for foreign body detection was 52.6% (95% confidence interval [CI] 48.9%-56.2%), and overall specificity was 47.2% (95% CI 39.9%-54.5%). Positive predictive value was 79.9% (95% CI 76.3%-83.5%), and negative predictive value was 20.0% (95% CI 16.2%-23.7%). Sensitivity for individual sonographers ranged from 40.8% to 72.3% (average 52.6% +/- 13.3%), and specificity ranged from 30% to 66.7% (average 47.2% +/- 15.1%). Inter-observer reliability was poor. In our model, bedside ultrasound performed by emergency physicians was neither sensitive nor specific for the presence of small soft tissue foreign bodies.

Use of ultrasound to assess acute fracture reduction in emergency care settings.

OBJECTIVE: There is a need to develop tools for the rapid diagnosis and treatment of fractures and intraosseous pathology in remote and austere environments. Several emergency and orthopedic studies have demonstrated ultrasound to be a reliable tool in diagnosing these conditions in both adult and pediatric patients. The purpose of this pilot study is to assess the ability of the ultrasound to assess in "real-time" the success of fracture reduction in adult patients in the emergency department (ED), in comparison with the accepted standard, plain film radiography, for the purposes of future application in austere environments. DESIGN: Case series. SETTING: Emergency department at an academic medical center. PATIENTS/PARTICIPANTS: Convenience sample of five patients presenting to an ED with clinical evidence of fractures (three radial, one phalangeal, and one metacarpal). INTERVENTIONS: A Sonosite Titan portable ultrasound system with L38/10-5:38-mm broadband linear array transducer was used to assess prereduction and postreduction angulations and alignment. Alignment was reconfirmed with use of fluoroscopy and plain radiography. RESULTS: The ultrasound confirmed proper reduction and realignment in all five cases, from an average prereduction angle of alignment of 37.4 degrees to an average postreduction angle of 4.4 degrees. The use of the ultrasound resulted in adequate visualization of the reduction in all cases. Regional anesthesia or sedation and limited pressure with the probe resulted in no verbalization of pain by any of the subjects. CONCLUSIONS: In this pilot study, emergency physicians demonstrated the use of ultrasound in place of traditional radiography to either confirm adequate reduction or assess the need for further manipulation. Our pilot study suggests that ultrasound has a possible future role in fracture reduction management in both the ED as well as "austere"prehospital locations.

Colchicine exposures: the Texas experience.

OBJECTIVES: Colchicine is a relatively uncommon toxin, but is known to precipitate severe multiorgan failure in overdose. Little is known about exposure patterns and outcomes in cases of colchicine ingestion. Our goal was to add to toxicologic knowledge through a database review and descriptive study of colchicine exposures. METHODS: Texas Poison Center Network Data was reviewed for the years 2000 to 2005, and all reports of colchicine exposures were reviewed. RESULTS: A total of 79 cases were found in the time period studied. The most common exposure reasons were unintentional-therapeutic error (33%), unintentional-general (28%), and intentional-suspected suicide (18%). Medical outcomes included no effect (24%), minor effect (20%), moderate effect (15%), and major effect (3%). The most common clinical findings included vomiting (20%), diarrhea (17%), and abdominal pain (7%). The most commonly employed therapies were dilution (28%), single-dose activated charcoal (26%), cathartics (16%), and gastrointestinal lavage (15%). CONCLUSION: The majority of cases of exposure produced no significant effects, and fatality was uncommon in this sample. Colchicine is a relatively uncommon toxin among therapeutic drugs, and though capable of it, is rarely responsible for significant morbidity or mortality. Meticulous exposure record keeping at poison centers is a key to the study of patterns of toxicity with uncommon toxins such as colchicine.

Trauma-induced pneumothorax after "bear-hug back crack" home remedy: attempted spinal manipulation by a layperson.

Spinal manipulation, as practiced by US-trained osteopathic physicians, is a safe and effective method of resolving patient pain and encouraging desirable physiologic improvement--often without pharmacologic intervention. Though novices, laypeople, and other clinicians also use manual techniques with similar goals in mind, their results are varied and sometimes dangerous to those they would help. The authors describe a case in which a layperson attempted spinal manipulation on a 20-year-old woman who later required a chest tube thoracostomy and hospitalization as a result of a pneumothorax. Osteopathic physicians are encouraged to consider patient risk factors for pneumothorax as a contraindication for the use of thoracic thrust techniques.