J Emerg Med
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Randomized Controlled Trial
Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study.
Subclavian vein puncture is commonly used in the intensive care unit (ICU) but is associated with complications. ⋯ Static ultrasound-guided subclavian vein puncture is superior to the traditional landmark-guided approach for critically ill patients in the ICU. It is suggested that static ultrasound-guided puncture techniques should be considered for subclavian vein puncture in the ICU.
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Telemedicine is uniquely positioned to address challenges posed to emergency departments (EDs) by the Coronavirus Disease 2019 (COVID-19) pandemic. By reducing in-person contact, it should decrease provider risk of infection and preserve personal protective equipment (PPE). ⋯ Telehealth can be safely and efficiently used to evaluate, treat, test, and discharge ED patients suspected to have COVID-19. This workflow reduces infection risks to health care providers, PPE use, and ED-LOS. Additionally, it allows quarantined but otherwise well clinicians to continue working.
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During the coronavirus disease 2019 (COVID-19) pandemic, healthcare systems in many regions of the country were being overwhelmed by large numbers of patients needing care. In this paper, we discuss use of an external emergency department (ED) site by a hospital system based in Charlotte, North Carolina to address concerns of a local surge similar to those seen around the country. ⋯ External expansion of the ED is an important strategy that can allow hospitals to accommodate potentially infectious patients while maintaining appropriate isolation and rapid throughput. Proper implementation of the right system to meet hospital-specific needs can prove effective for the healthcare system.
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Traumatic tension pneumocephalus is a rare complication after craniofacial fractures that can cause devastating neurologic deficits if not managed promptly and effectively. ⋯ A 38-year-old man with no past medical history presented to the Emergency Department (ED) after a motor vehicle crash. He was noted to have an open frontal scalp laceration. Computed tomography (CT) revealed a right frontal subdural hematoma and right medial frontal contusion. There was also a frontal bone fracture extending through the frontal sinus with mild underlying pneumocephalus. He was monitored for cerebrospinal fluid (CSF) leak and was subsequently discharged on postinjury day 9. He re-presented to the ED 14 days post injury with lethargy, confusion, headache, and swelling around his scalp laceration. A CT scan was obtained that revealed a large-volume intraparenchymal pneumocephalus (pneumocerebri) with mass effect and midline shift. The patient was started on 100% oxygen and admitted to the intensive care unit. He was taken to the operating room for evacuation of the pneumocerebri, repair of dural defect, placement of a vascularized pericranial graft, and placement of a lumbar drain. His lumbar drain was removed on postoperative day 3 and he was discharged home neurologically intact on postoperative day 6. At 1 month follow-up he had no evidence of CSF leak and was neurologically intact. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case is presented to increase awareness among emergency physicians that traumatic tension pneumocephalus, and in this case, pneumocerebri, is a rare life-threatening neurosurgical emergency in patients with severe craniofacial fractures after blunt or penetrating head trauma. Early temporizing measures in the ED, such as 100% oxygen via nonrebreather face mask, and urgent neurosurgical consultation are indicated to prevent neurologic deterioration.
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The Bezold-Jarisch reflex is a depressor reflex of the heart due to the preferential distribution of vagal nerves in the inferior wall of the left ventricle. We report a case of Stanford type A acute aortic dissection, in which coronary spastic angina caused the Bezold-Jarisch reflex in the acute phase. ⋯ A 53-year-old man presented with left chest pain and cold sweating. An electrocardiogram was normal and the high-sensitivity cardiac troponin T level was negative. A diagnosis of Stanford type A acute aortic dissection was made based on computed tomography (CT); there was no evidence of ischemic heart disease on coronary CT angiogram obtained simultaneously. While waiting for emergency surgical repair, chest pain worsened, followed by bradycardia and hypotension, along with ST-segment elevations in the inferior leads, all of which were resolved by conservative treatment. During surgery, no evidence to suggest an extension of the dissection to the ostium of the right coronary artery was observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing the Bezold-Jarisch reflex because this depressor reflex may require different management than other conditions.