Emergency Physicians Research Articles

Practice and outcomes of endotracheal intubation in the emergency department: a retrospective observational study at a single institution in Bhutan

Abstract Background Airway management is a critical skill required in the Emergency Department (ED). We conducted an observational airway registry-based study to report the practice and outcome of endotracheal intubations in the ED at the national referral hospital in Thimphu. Methods All patients who were intubated in the ED and recorded on the registry data form between May 2020 to November 2022 were studied. Variables such as indications, type of physician performing intubations, success rate, complications, medications, and disposition were captured. Descriptive analysis was presented in frequency and proportions. Results There were a total of 336 intubations during the study period. First pass success rate was 87.80% and complication rate was 19.64%. 40 patients (11.90%) needed a second attempt and only 1 patient required a third attempt. Most intubations were performed by emergency medicine (EM) residents (54.17%), followed by medical officers (37.8%). Emergency Physician (EP) performed the least number of intubations, 27 (8.04%). During preoxygenation, 64.5% (n = 217) patients received positive pressure ventilations and 119 (35.42%) did not. Conclusion Physicians working in the ED are the primary airway provider. First pass success rate was 87.80%. 40 patients (11.90%) needed a second attempt and only 1 patient required a third attempt.

Ultrasound-Guided Nerve Blocks for Flexor Tenosynovitis

Performing an ultrasound-guided nerve block (UGNB) is now common practice in many emergency departments (EDs) and is considered a core skill according to the American College of Emergency Physicians (ACEP). Nerve blocks are mostly utilized for fractures and laceration repairs, however, these blocks have many other applications. We present a case of utilizing an ulnar UGNB in a patient with flexor tenosynovitis and a history of intravenous drug use (IVDU) when parental opiates proved to be ineffective.

Safety and accuracy of the computer interpretation of normal ECGs at triage.

ECGs performed at ED triage are mandatorily assessed by an emergency physician contributing to task interruptions, decreased quality of care and increased error risk. Recent literature suggests that a triage ECG interpreted as normal by the ECG machine software correlates with benign interpretation from attending cardiologists.Ambiguity persists regarding the safety of the normal computerized ECG interpretation and whether real-timephysician review is needed. In this prospective cohort study, we evaluated the GE Marquette 12SL ECG software's clinical accuracy for normal triage ECGs. We compared machine interpretation, ED physicians' real-time interpretation and management as well as cardiologists systematic but delayed review of the ECGs to establish diagnostic accuracy and safety of a normal software interpretation. Additional data were collected from the emergency department patient tracking system and charts to determine patient outcomes when machine normal interpretation differed from ED physicians and cardiologists' analysis. Between November 16th 2020 and November 19th 2021, we collected 1220 machine-normal ECGs performed at Charles-Le Moyne Hospital ED triage. 1051 ECGs were eligible for inclusion. ED physicians agreed with the machine for 1028 normal diagnoses (97.8% IC (0.95): 96.7-98.5) and cardiologists agreed with the machine for 1037 ECGs (98.7% IC (0.95) 97.8-99.2). Relevant changes in ED management were recorded in three patients (0.29% IC (0.95): 0.1-0.8) whose ECGs were read as normal by the software: two emergent referrals to the catheterization lab and one emergent transfer to the resuscitation bay with next day coronarography. A normal ECG interpretation from the GE Marquette 12SL ECG software at ED triage has a very high accuracy and a very low probability of clinically relevant change in patient outcome and ED trajectory.

Tropical Primary Pyomyositis of The Right Calf Muscle: A Rare and Unexpected Complication of Jump Squat Exercise

Diagnosing pyomyositis in its initial or invasive stages can pose a challenge due to its vague initial symptoms, which may mimic other conditions such as muscle strain, localized myositis, hematoma, deep vein thrombosis, cellulitis, or thrombophlebitis. A high index of suspicion for possible pyomyositis necessitates confirmation through radiographic imaging. A delayed diagnosis directly correlates with the time taken to commence treatment, thereby increasing the risk of patient morbidity and mortality. We present a case of a diabetic male who experienced bilateral calf muscle pain and right calf swelling after participating in jumping squat exercises, eventually developing right calf myositis and abscesses over a two-week period, which were initially overlooked by several general practitioners. This case underscores the crucial role of radiographic imaging in confirming the diagnosis, whether in the Emergency Department or any primary care setting. Prompt diagnosis and intervention, as demonstrated here, are imperative for minimizing the risks associated with this potentially severe disease. Knowledge of this condition and its diagnostic methods is highly advantageous for emergency physicians, primary care providers, and family physicians.

Online public response to emergency department diagnostic error report: A qualitative study.

The 2022 study on diagnostic error in the emergency department (ED) published by the Agency for Healthcare Research and Quality (AHRQ) reported that one in every 18 ED patients is misdiagnosed. The report was methodologically critiqued by emergency physicians and researchers. However, little is known about public perception of error in the ED. We sought to characterize public response to AHRQ's publication. A search was conducted for online news articles published December 2022 reporting the AHRQ study and containing "public comment" sections. Verbatim comments and relevant characteristics were collected. Three coders completed content analysis and resolved any differences. Descriptive statistics and themes are reported. Fifteen online articles were reviewed; three had public comment sections (New York Times, DailyMail, and Boston Globe). There were 553 unique user comments; 293 were original comments (53%) and 260 were replies to comments (47%). The 260 replies were in response to 113 original comments, with the remaining original comments having 0 replies (n = 180). Of the 202 commenters who identified a personal role in a health care encounter, 70 (35%) identified as patients and 68 (34%) identified as physicians. Comments centered on seven major themes: (1) negative personal experiences, (2) reframing study conclusions, (3) sense of decline in training standards, (4) internal stressors impeding ED diagnostic accuracy, (5) external stressors impeding ED diagnostic accuracy, (6) suggested solutions, and (7) role of the ED in diagnosis. The news coverage of AHRQ's report provided individuals a platform to share their perspectives. Many comments reflected a nuanced understanding of the role of emergency care and the stressors of the ED environment. Despite questions about the report's accuracy, there were many individuals who shared personal negative experiences suggesting that the public may feel directly impacted by error in the ED.

Abstract Su1202: The utility of post cardiac arrest temperature control protocol according to the severity of hypoxic encephalopathy based on amplitude-integrated electroencephalography findings

Introduction: The TTM2 trial showed that active fever prevention below 37.5°C and hypothermia at 33°C had similar outcomes in out-of-hospital post cardiac arrest patients. However, the patients in the trial had mild hypoxic encephalopathy, and the effects of hypothermia may vary with its severity. We previously reported that amplitude-integrated electroencephalography (aEEG) findings after the return of spontaneous circulation can be used to categorize the severity of hypoxic encephalopathy (Crit Care. 2018;22:226). In September 2022, we adopted a new temperature control protocol wherein the target temperature was set based on aEEG findings. This study examined changes in outcomes before and after implementing this new protocol. Methods: We assessed out-of-hospital cardiac arrest patients who received post cardiac arrest care in our emergency intensive care unit between March 2021 and February 2024. We divided the patients into two groups: before (B) and after (A) the introduction of the new protocol. We classified the patients into categories 1 (C1) to 4 (C4) based on the severity of hypoxic encephalopathy (Figure 1). All patients in group B were treated with hypothermia at 34°C. In group A, patients in C1 were treated with active fever prevention, and those in C2–C4 received hypothermia at 34°C (Figure 2). Primary outcome was favorable neurological outcomes (cerebral performance categories of 1 or 2) at hospital discharge. Secondary outcome was the duration of mechanical ventilation. Results: A total of 160 patients were included. The median age was 62 years and 105 (66%) patients had cardiac etiology. Fifty-five (34%) patients underwent extracorporeal cardiopulmonary resuscitation. The median cardiac arrest time was 29 min. Groups B and A comprised 57 and 103 patients, respectively. C1 category comprised 20 and 28 patients in groups B and A, respectively. The rate of favorable neurological outcomes was 35% in both B and A groups (p=1.00). Regarding C1 patients, the rates were 90% and 86% in B and A groups (p=1.00). Median duration of mechanical ventilation was 5 and 3 days in group B and A, respectively (p=0.11). Conclusion: Neurological outcomes before and after introducing the new protocol were similar. Management of patients with mild hypoxic encephalopathy can be simplified with active fever prevention. A temperature control protocol based on the severity of hypoxic encephalopathy using aEEG findings is feasible for emergency physicians.

An Observational Study of Patients Presenting in Hypotension and Shock to Emergency Room by Applying RUSH Protocol

Introduction: Care of the patient with shock can be one of the most challenging issues in emergency medicine. The early use of ultrasound at the bedside in such emergency is a very valuable tool to determine the type of shock. Rapid Ultrasound in SHock (RUSH) protocol done by emergency physicians is one such protocol which is being underused. Hence, we conducted this study to assess the effectiveness of the RUSH protocol for patients presenting with undifferentiated hypotension and shock. Materials and methods: This was prospective observational study done on a total of 100 patients presented with hypotension and shock. We performed an early bedside sonographic examination for participants based on RUSH protocol and type of shock was determined. Then the definitive interventions were performed as per the type of shock. The outcome measures were determined either till the survival to discharge from the hospital or till the in-hospital death of the patient. The data was analysed using SPSS version25. Results: In this study, the type of shock most commonly found overall was hypovolemic shock (40%) followed by cardiogenic shock (27%) and distributive shock (17%). Contractility of left ventricle, size of right ventricle, inferior venacava caliber, hemoperitoneum, pneumothorax, hemothorax, pulmonary edema, pleural effusion and lungs consolidation were statistically significant in determining the type of shock except cardiac tamponade, abdominal aortic aneurysm/dissection and deep vein thombosis. Majority of the interventions performed were fluid resuscitation (41%), vasopressors and inotropes (28%) and laparotomy (9%) and were statistically significant (p=0.001). Among all patients, 73% survived and 27% died. The outcome was statistically significant (p=0.002). Conclusion: RUSH protocol used for undifferentiated hypotension and shock is an effective tool at the bedside as an early approach to diagnose the type of shock. It will also help in determining early definitive interventions in shock states and thereby having better patient outcomes.

Stroke in the young: infective endocarditis due to mitral valve prolapse leading to acute ischemic stroke and subsequent hemorrhagic transformation

BackgroundStroke in young needs an individualized approach before considering thrombolysis. Here we present a case of undiagnosed mitral valve prolapse presenting with stroke due to associated infective endocarditis. Young stroke patients presenting with fever need a panoramic approach.Case summaryThis 39-year-old female with a background history of fever and loss of weight for two months presented to the emergency department with a history of altered sensorium and aphasia. The Magnetic Resonance Imaging (MRI) showed a hyperacute infarct. Hence, thrombolysis with alteplase was considered. Post thrombolysis, the patient had a parenchymal bleed. The diagnostic evaluation yielded stroke secondary to infective endocarditis because of undiagnosed mitral valve prolapse.ConclusionMitral valve prolapse is not associated with stroke in young patients. However, the undiagnosed infective endocarditis and subsequent septic emboli led to an increased risk. Emergency physicians and intensivists should anticipate infective causes before considering thrombolysis, as the results could be counterproductive.

Knowledge and awareness of emergency department residents and physicians regarding the management of dentofacial traumatic injuries: a cross-sectional study

BackgroundMajority of patients with Dento-Facial Traumatic Injuries (DFTI) seek initial care at an Emergency Department (ED). The timely management of DFTI is of utmost importance in determining long-term prognosis of the tooth and the patient’s overall quality of life. Thus, knowledge and awareness of ED residents & physicians regarding the management of DFTI is crucial for better patient outcomes. Numerous studies have investigated the knowledge of ED specialists regarding initial management of dental trauma, however, scientific evidence in this domain is scarce in our region.ObjectiveThe aim of this study was to evaluate the knowledge and awareness of ED residents and physicians regarding diagnosis and management of DFTI using a web-based survey on REDCap.MethodsAn observational cross-sectional study was conducted among the ED residents and physicians of private and public hospitals in Karachi, Pakistan. Data was collected through a web-based questionnaire, sent via email to the participants. The survey comprised of questions assessing their knowledge regarding the diagnosis and management of various dental and maxillofacial injuries. Responses from the participants were graded as low, moderate or high knowledge levels according to a pre-determined criteria. Pearson’s chi-square test was applied to determine the association between knowledge scores.ResultsThe total response rate was 47.6%. Out of 116 participants, 49 (42%) responses were received from physicians and 67 (58%) from residents. The overall knowledge level of participants was low (46.6%) and there was no significant difference in the knowledge level between residents and physicians (p = 0.157). Participants who had received formal training in dental trauma (p = 0.038) and those with more years of clinical experience (p = 0.004) had higher knowledge scores, that were statistically significant.ConclusionsThe knowledge and awareness of ED residents and physicians in dental trauma management was generally low. Specialized training courses are required to provide timely and adequate management of traumatic dental injuries in order to improve patient-related outcomes.

“Caught in the middle”- emergency doctors and nurses’ experiences of ethical dilemmas in end of life care: A qualitative study

ObjectiveThe integration of end of life care into emergency work is gaining momentum, especially in Australia. Emergency doctors and nurses are increasingly required to make decisions regarding the provision of end of life care. The importance of end of life care for patients and their families in the emergency department is well documented, but ethical dilemmas that arise in end of life care provision are not widely researched. MethodsA qualitative interpretative design and phenomenological approach were used to create an understanding and meaning about ethical dilemmas faced by emergency nurses and doctors in end of life care. Sixteen doctors and nurses were purposively recruited through professional organisations. Data were collected using semi-structured in-depth interviews. Interviews were audio-taped, transcribed verbatim, and thematically analysed using a qualitative seven stage thematic analysis. ResultsThe overarching constitutive pattern ‘decision making processes’ was conceptualised within the two identified major themes including: 1) Short-term (ST) versus Long-term (LT) ethical dilemmas and; 2) Individual versus community ethical dilemmas. These themes were uncovered using the phenomenological hermeneutic concepts of epoche (openness) to construct meaning and understanding for participants. ConclusionsIn this study, the frequent experiences of ethical dilemmas by emergency doctors and nurses demonstrated that end of life care in the emergency department was challenging. The stated experiences were related to barriers that contributed to the complexities reported in making ethical decisions at the end of life. Therefore, an understanding of ethical principles is needed to navigate care for patients and their families for the best possible outcomes.

Clinical significance of the modified Hinchey classification of acute diverticulitis

BACKGROUND: In recent decades, there has been a widespread increase in the incidence of diverticular disease by more than 10 times and an increase in the frequency of its complications in the range from 5 to 25%. AIM: To present the clinical experience of implementing the classification of acute diverticulitis according to E.J. Hinchey (1978) modified by A.M. Kaiser (2005). MATERIALS AND METHODS: The srudy considered the hospitalizations of 314 patients with complicated diverticulitis; the patients were divided according to the Hinchey’s classification into 6 groups depending on the complications. RESULTS: This classification allows not only to stage the disease depending on the severity of the complications, but also to verify these complications with the results of X-ray computed tomography. The modern methods of their correction, which were applied in the Republican Clinical Hospital (Kazan), are given. CONCLUSIONS: The widespread use of the classification by therapists, surgeons, coloproctologists, and emergency doctors will ensure timely and effective treatment tactics, predict the dynamics of the inflammatory process, and manage the flow of patients with this pathology.

Early diagnosis of nonconvulsive status epilepticus due to lithium intoxication using 6-channel electroencephalography.

Nonconvulsive status epilepticus is a severe complication of lithium intoxication that requires prompt diagnosis and treatment. While conventional electroencephalography (EEG) remains the gold standard for diagnosis for nonconvulsive status epilepticus, its implementation in emergency settings can be challenging and time-consuming. We present a case in which simplified EEG with six electrodes enabled rapid detection and monitoring of nonconvulsive status epilepticus in lithium intoxication in the emergency setting. A 65-year-old woman with stable bipolar disorder presented to our emergency department with impaired consciousness. She had been maintained on lithium carbonate (1600mg daily) and carbamazepine (400mg daily) for over 10 years. Following two weeks of nausea and recent onset of agitation and slurred speech, she developed generalized convulsions. Laboratory examinations revealed elevated serum lithium (3.88 mEq/L) and acute renal dysfunction (creatinine 347.5μmol/L). After resolving initial convulsions, a simplified sixelectrode EEG (Neurofax EEG-1250, Nihon Kohden Corporation, Tokyo, Japan), applied by an emergency physician, demonstrated generalized spike and wave patterns consistent with nonconvulsive status epilepticus. Despite initial seizure control with midazolam during intubation, continuous EEG monitoring revealed recurrent nonconvulsive status epilepticus. After hemodialysis and continued deep sedation, she was discharged on day 40 without neurological sequelae. This case demonstrates the utility of simplified EEG in emergency settings for early detection and monitoring of nonconvulsive status epilepticus in lithium intoxication. The ability of emergency physicians to apply and interpret simplified EEG enabled timely intervention and prevention of neurological complications. While further research is needed to validate interpretation protocols by non-EEG specialists, simplified EEG shows promise as an accessible tool for rapid assessment of neurotoxicity in lithium intoxication, potentially improving patient outcomes through earlier intervention.

“Where Are They Now? Attrition Rates of EM residency graduates by Gender”

Prior studies examined the retention of women emergency physicians through residency training, but their career paths on completing residency are less well understood. Our primary objective was to identify a difference in attrition rates between binary genders of practicing clinical emergency physicians within 10 to 30 years after residency graduation. Our secondary aims investigated gender differences in geographic practice location, academic, and community practice. We hypothesized that women emergency physicians have higher rates of attrition from clinical practice than men. In this cohort study, we tracked employment over 10 to 30 years of graduates from allopathic emergency medicine residency programs established before 2005 and those who graduated before 2010. We obtained graduate lists from 21 residency programs representing geographically diverse training programs in the United States. We utilized public databases to investigate current licensure, board certification, practice location, and occupation for graduates more than 10 years after residency graduation. Physicians who do not practice clinically in emergency medicine or an emergency medicine subspecialty were placed in the "attrition" category. "Not available" was defined as those individuals who did not have adequate information available online. We analyzed differences in attrition of women and men emergency physicians in clinical practice in 2020. We also noted whether they worked in an academic or community setting and assessed their geographic clinical practice region. We identified a total of 4,170 graduates. Of those, 445 (10.6%) were excluded because of insufficient information. Of the 3,725 emergency medicine residency graduates, 71% were men. The attrition rate from clinical emergency medicine for men was 5.3% (95% confidence interval, 4.4% to 6.1%) and the attrition rate for women was 5.8% (95% confidence interval, 4.4% to 7.2%). The difference between the 2 proportions was -0.005 (95% confidence interval, -0.02 to 0.01). There were no gender differences in geographic location or practice type. We did not observe differences in attrition rates by gender in our sample from 21 programs over a 30-year period. The findings from this cohort are disparate from reports of recent emergency medicine graduates and identifying reasons for attrition of emergency physicians will be important to understanding the workforce needs of the future.

A Change of Pace: Modifying Pacemaker Settings in the Emergency Department as Emergency Medicine Physicians, A Case Report

Background: Pacemakers are implantable or external devices that send electrical impulses allowing the heart to contract. Some common indications for permanent pacemaker placement include symptomatic bradycardia due to high grade atrioventricular (AV) block, sick sinus syndrome, chronic bifascicular block, and post-cardiac transplantation. Like all devices pacemakers can malfunction or stop working entirely. We present a patient with an implantable pacemaker/cardioverter and defibrillator (ICD) displaying symptomatic failure to capture and settings were adjusted in the emergency department. Adjustment in the emergency department (ED) resolved the patient's symptoms and required no further interventions.Case Report: An 82-year-old female with atrial fibrillation, heart failure, and a Medtronic dual chamber pacer/ICD presented to the emergency department for complaints of weakness and lightheadedness. Emergency medical services (EMS) noted intermittent bradycardia, hypotension, and decreased responsiveness. Electrocardiogram (ECG) revealed failure to capture. The Medtronic application was used to interrogate and reprogram the device. The settings were DDD at a rate of 60 beats per minute (BPM) with ventricular output of 4.5 millivolts (mV) and atrial output of 4.5 mV which were changed ventricular lead outputs from 4.5 mV to 8.0 mV and rate from 60 to 80 for additional cardiac output. After this adjustment, the bradycardia resolved, and ECG showed a successful AV-paced rhythm. Transcutaneous pacing was never required.Why should an emergency physician be aware of this?Adjustment of pacer settings in the ED in order to stabilize the critically ill patient is within the scope of the emergency physician. We can reduce stress to the patient and prevent hospitalizations. Pacemakers can become a tool to optimize treatment plans for an aging population where pacemakers are becoming more common.

Use of an endotracheal tube for a thoracostomy in a child in cardiac arrest: A case report

Background: Traditionally when patients arrive at an Emergency Department in cardiac arrest with a concern for a pneumothorax, a thoracostomy tube is placed for decompression. In a literature review, there are no case reports of an endotracheal tube being used in lieu of a thoracostomy tube for a pneumothorax in a child in cardiac arrest.Case Presentation: We present a case of a 4-week-old female infant who presented to the Emergency Department in cardiac arrest with a pneumothorax.Why should an emergency physician be aware of this?: It is important for clinicians to be aware of alternative management strategies for the management of a pneumothorax. Our case suggests that an endotracheal tube being used as a thoracostomy tube in a child in cardiac arrest can help acutely treat a pneumothorax by providing immediate and continuous decompression. In a prehospital or low-resource setting, an endotracheal tube may offer similar benefits to a thoracostomy tube as an immediate treatment modality.

Case Report of an Obstructive Endobronchial Mass from a Blood Clot: An Airway Nightmare

BackgroundCentral airway obstruction from a mass is a rare but deadly manifestation of advanced primary lung cancer that can cause significant challenges during endotracheal intubation, including airway debris or bleeding, ventilation difficulties, and prolonged post-intubation hypoxia. Case reportThis case report describes a patient presenting with the chief complaint of massive hemoptysis who was difficult to ventilate and oxygenate after an easy intubation. On bedside bronchoscopy, an obstructing mass was found at the carina that was later determined to be caused by a blood clot. Patient course was complicated by tension pneumothoraces, prolonged hypoxia and cardiopulmonary arrest. Why should an emergency physician be aware of thisEarly recognition of an obstructing airway mass can be achieved with bedside fiberoptic bronchoscopy and allow for prompt mobilization of specialty services with rigid bronchoscopy capabilities for mass removal.

Streptococcal Toxic Shock Syndrome: A Case Series Emphasizing the Urgency of Recognition and Tailored Treatment

BackgroundStreptococcal toxic shock syndrome (TSS) is a rare but lethal condition associated with Streptococcus Pyogenes Group A (GAS). With rising incidence and high mortality, timely recognition and management are crucial. This case series presents two adult TSS cases caused by invasive GAS, highlighting the importance of early identification and multidisciplinary management. Case PresentationsThe first case involves a 42-year-old male who presented with fever, dizziness, and a tender, erythematous olecranon following an elbow laceration. Despite negative imaging for necrotizing fasciitis, a positive throat swab for GAS prompted immediate broad-spectrum antibiotics and aggressive resuscitation. Clindamycin and intravenous immunoglobulin (IVIG) were administered. The patient developed TSS and acute kidney injury, requiring intensive care and hemodialysis.The second case features a previously healthy 43-year-old female presenting with systemic symptoms and a rash, without trauma history. Positive GAS blood cultures confirmed TSS, leading to similar management and subsequent renal complications requiring hemodialysis. Why should an Emergency Physician be aware of this?These cases highlight the evolving epidemiology of invasive GAS infections and the associated risk of TSS. Early identification and appropriate tailored treatment are essential to reduce morbidity and mortality, especially given the recent surge in invasive GAS. Clinical vigilance for skin changes and thorough laboratory investigations, including non-sterile site cultures, are critical. Early identification enables the use of adjunctive treatments like clindamycin and IVIG, and facilitates appropriate de-escalation of antibiotics. Prompt consultation with infectious disease, intensive care, and surgical teams is necessary to ensure optimal treatment.

The Ten Test and Sensory Evaluation of Hand and Finger Injuries in the Emergency Department

BackgroundHand and finger injuries are a common presenting complaint to the emergency department and are associated with significant morbidity. Neurologic evaluation of these injuries is a crucial component of the patient assessment and can be done via a variety of testing methods. DiscussionWhile most taught and cited in the emergency department literature, the two-point discrimination (2PD) test for sensation has several drawbacks, including limited reproducibility and reliability. While often utilized by hand surgical specialists, the Semmes-Weinstein monofilament (SWM) test and the Weinstein Enhanced Sensory Test (WEST) are not practical for the emergency physician due to the need for specialized equipment and frequent calibration. The ten test, a relatively new sensory evaluation method, has been shown to be reliable, reproducible, and pragmatic in varying types of clinical environments. ConclusionThe ten test is a pragmatic alternative method of evaluation to two-point that is utilized by specialists in hand surgery and injuries. The emergency physician should consider adding the ten test to their evaluation and reporting of hand and finger injuries in the emergency department.

Point-of-care ultrasound diagnosis of acute valvular emergencies

IntroductionAcute valvular emergencies, a time-sensitive diagnosis, are nearly impossible to diagnose without ultrasound, and missing the diagnosis can significantly impact patient outcomes. Many emergency physicians lack access to echo technicians and may be uncomfortable performing the ultrasound themselves. Approaching the paucity of review articles, none of which are focused for the emergency physician, can be quite daunting, even for those with extensive ultrasound training. ObjectiveOur goal is to provide a simple resource for emergency physicians to utilize ultrasound to diagnose acute valvular emergencies. We created a concise review that includes relevance and approach to the diagnosis, complete with live ultrasound images, reference cards, and focused figures for in-the-moment reference. MethodsA team of ultrasound fellowship-trained emergency medicine physicians determined the highest yield emergent conditions and oversaw the project. Each team member reviewed the etiology, incidence, and level of evidentiary support for each condition and then provided a guide to the appropriate procedure and evaluation with relevant additional guidance. An in-house graphics team was consulted to prepare original, concise figures for easy reference. All sections of the manuscript and figures were reviewed for accuracy and ease of use. DiscussionCritical aortic stenosis, infective endocarditis, left ventricular outflow tract obstruction, mitral stenosis, and mitral regurgitation were identified diagnoses for which ultrasound can provide immediate diagnostic information for emergency physicians. ConclusionThe use of ultrasound in the emergency department setting is a critical adjunct to care for patients with acute valvular emergencies. One should always consider a comprehensive, cardiology-performed echocardiogram in these scenarios.

Navigating trauma airway responsibilities in the Modern Emergency Department: A survey of emergency physicians

Navigating trauma airway responsibilities in the Modern Emergency Department: A survey of emergency physicians