J Emerg Med
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Distal forearm fractures are a commonly encountered injury in the emergency department (ED), accounting for 500,000 to 1.5 million visits and 17% of ED fractures. The evaluation and management of these fractures frequently employs x-ray studies, conscious sedation, closed reduction, and splinting. Point-of-care ultrasound (POCUS) can offer significant benefit in the diagnosis and management of these common injuries. ⋯ Distal forearm fractures are common, and the emergency physician should be adept with the evaluation and management of these injuries. POCUS can be a reliable modality in the detection of these fractures and can be used to facilitate analgesia and augment success of reduction attempts. These techniques may decrease length of stay, improve patient pain, and decrease reduction attempts.
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Multicenter Study
Six Diagnoses of Separation: Impact of COVID-19 on Pediatric Emergency Department Visits: A Multicenter Study.
Coronavirus disease 2019 (COVID-19) arrived in the New York metropolitan area in early March 2020. Recommendations were made to self-quarantine within households and limit outside visits, including those to clinics and hospitals, to limit the spread of the virus. This resulted in a decrease in pediatric emergency department (ED) visits. However, it is unclear how this affected visits for some common diagnoses such as anxiety, appendicitis, asthma, headaches, seizures, and urinary tract infection (UTI). These diagnoses were chosen a priori, as they were felt to represent visits to the ED, for which the diagnoses would likely not be altered based on COVID exposure or quarantine due to their acute nature. ⋯ We found a marked decrease in ED visits for six common pediatric diagnoses after COVID-19 arrived in our area. We suspect that this decrease was due to recommendations to quarantine and fear of contracting the virus. Further studies on other diagnoses and potential complications due to the delay in seeking care are needed.
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Case Reports
A Pressing Matter: Compressive Postoperative Hematoma Causing Acute Diastolic Heart Failure.
Cardiopulmonary complications in the postoperative period can lead to significant morbidity and mortality. Many of the complications in the postoperative period occur after discharge from the hospital, and up to 25% of patients will require readmission. In postoperative patients presenting to the emergency department (ED), it is important to consider that postoperative complications can affect a multitude of organ systems, including those that are adjacent to where the surgery was performed. ⋯ We present the case of a 54-year-old woman presenting to the ED with shortness of breath in the setting of recent Nissen fundoplication revision. Pulmonary angiography was significant for a large hiatal hernia and negative for pulmonary embolism. She was discharged and returned to the ED a few days later due to worsening symptoms. Further diagnostic studies demonstrated an esophageal hematoma causing compression of the left atrium, leading to acute diastolic heart failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to consider alternative etiologies for common complaints in the postoperative patient presenting to the ED. Early involvement of the operative team in the patient's care can assist in directing diagnostic approach and management of the postoperative patient.
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Clinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described. ⋯ A 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS.
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Coronavirus disease 2019 (COVID-19) placed additional strain on an already struggling health care system. In response, novel solutions such as telehealth have been explored, however, there is significant room for innovation in health care delivery. ⋯ Drive-through medical systems can accurately triage patients presenting with potential COVID-19 and effectively treat lower-risk patients, thereby reducing ED utilization.