Optimizing Non-invasive Oxygenation for COVID-19 Patients Presenting to the Emergency Department with Acute Respiratory Distress: A Case Report.

INTRODUCTION: The novel coronavirus (COVID-19) pandemic has led to an increase in the number of patients presenting to the emergency department (ED) with severe hypoxia and acute respiratory distress. With limited resources and ventilators available, emergency physicians working at a hospital within the epicenter of the United States outbreak developed a stepwise, non-invasive oxygenation strategy for treating COVID-19 patients presenting with severe hypoxia and acute respiratory distress. CASE REPORT: A 72-year-old male suspected of having the COVID-19 virus presented to the ED with shortness of breath. He was found to be severely tachypneic, febrile, with rales in all lung fields. His initial oxygen saturation registered at SpO2 (blood oxygenation saturation) 55% on room air. Emergency physicians employed a novel non-invasive oxygenation strategy using a nasal cannula, non-rebreather, and self-proning. This approach led to a reversal of the patient's respiratroy distress and hypoxia (SpO2 88-95%) for the following 24 hours. This non-invasive intervention allowed providers time to obtain and initiate high-flow nasal cannula and discuss end-of-life wishes with the patient and his family. CONCLUSION: Our case highlights a stepwise, organized approach to providing non-invasive oxygenation for COVID-19 patients presenting with severe hypoxia and acute respiratory distress. This approach primarily employs resources and equipment that are readily available to healthcare providers around the world. The intent of this strategy is to provide conventional alternatives to aid in the initial airway management of confirmed or suspected COVID-19 patients.

Case Report: Disposition of Symptomatic Probable COVID-19.

INTRODUCTION: The novel coronavirus disease 2019 (COVID-19) presents a challenge for healthcare providers in terms of diagnosis, management, and triage of cases requiring admission. CASE REPORT: A 47-year-old male with symptoms suspicious for COVID-19, pulse oximetry of 93% on room air, and multifocal pneumonia was risk stratified and safely discharged from the emergency department (ED) despite having moderate risk of progression to acute respiratory distress syndrome. He had resolution of his symptoms verified by telephone follow-up. CONCLUSION: Various risk-stratifying tools and techniques can aid clinicians in identifying COVID-19 patients who can be safely discharged from the ED.

Points & Pearls: Evaluation and management of life-threatening headaches in the emergency department

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition. [Points & Pearls is a digest of Emergency Medicine Practice.]

Evaluation and management of life-threatening headaches in the emergency department.

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition.

Patient-Centered Communication Behaviors That Correlate With Higher Patient Satisfaction Scores.

BACKGROUND: With increased emphasis on improving the patient experience, clinicians are being asked to improve their patient-centered communication behaviors to improve patient satisfaction (PS) scores. LOCAL PROBLEM: The relationship between clinician communication behaviors and PS is poorly studied in the emergency department (ED) setting. The purpose of this study was to identify whether specific communication behaviors correlate with higher PS scores in the ED setting. METHODS: During a quality improvement project, we performed 191 bedside observations of ED clinicians during their initial interaction with patients and recorded the frequency of 8 positive communication behaviors as defined by the PatientSET tool. INTERVENTIONS: The frequency of use of the PatientSET communication behaviors was compared between known high performers in Press Ganey PS scores versus low performers. RESULTS: Being a high Press Ganey performer was associated with a significantly higher frequency of performance in 6 of the 8 PatientSET communication behaviors. CONCLUSIONS: Positive communication behaviors such as those in the PatientSET tool occurred more frequently in ED clinicians with higher PS scores.

Severe malaria presenting to the ED: A collaborative approach utilizing exchange transfusion and artesunate.

We describe the case of a previously healthy 33year-old male pilot recently arrived to the United States from Africa. The patient presented to our ED febrile and disoriented, with projectile coffee-ground emesis. He was later found to have severe malaria and cerebral parasitemia. Due to the severity of his illness, the patient received the anti-malarial medication Artesunate as well as several exchange transfusions. Within 48h his parasitic load was reduced from 42% to 0.4%. The following is an account of a collaborative effort that spans the specialties of emergency medicine, infectious disease, and critical care medicine.

A Novel Case of Splenic Injury After Shockwave Lithotripsy.

BACKGROUND: Emergency departments (EDs) are gateways for patients presenting after minor surgical procedures, particularly shockwave lithotripsy. Complications include renal and extrarenal tissue injuries, with the latter having potentially serious consequences if not detected early. CASE REPORT: We describe a 70-year-old male presenting to the ED for syncope. The patient underwent shockwave lithotripsy (SWL) for left kidney stones 1 day prior. Upon initial evaluation, the patient had normal vital signs and a normal physical examination, without complaints of abdominal pain. Close observation and regular patient re-evaluation led to the diagnosis of life-threatening injuries that included splenic rupture. Although this is a rare complication of SWL, with only eight published cases found in the literature, the patient's initial presentation of syncope without complaints of abdominal pain presented a unique diagnostic challenge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be knowledgeable of the pre-existing conditions linked to higher rates of complications after shockwave lithotripsy and be able to identify and manage these potentially life-threatening complications.

Allergy And Anaphylaxis: Principles Of Acute Emergency Management.

Allergic reactions and anaphylaxis are potentially life-threatening processes that present with a variety of clinical symptoms. Emergency clinicians must be able to recognize these presentations and make prompt clinical decisions regarding management of a patient's airway, treatment options, and disposition of a patient who improves after initial presentation. Furthermore, emergency clinicians may be faced with patients who have atypical presentations or require special consideration, such as high-risk patients with comorbid conditions and patients who do not respond to first-line treatments. An increasing number of patients in the United States carry allergy diagnoses, and it is expected that this subset of the population will continue to seek care in the emergency department. This review assesses the research and evidence on the diagnosis, etiology, and treatment of anaphylaxis, as well as the utilization of epinephrine, both in and out of the hospital setting.