Acute Aortic Dissection Presenting with Massive Hemoptysis and History of TAVR

Aortic dissection is a rare and life-threatening condition that frequently mimics more common causes of chest pain. This often leads to a missed or delayed diagnosis which can have disastrous consequences for the patient. It is imperative that physicians recognize the variable presentations of this life-threatening illness as early diagnosis and treatment are crucial to the outcome of the patient. We present the case of a 77-year-old female with a past medical history of hypertension, aortic stenosis, TAVR, and ESRD, who presented to the ED with chest pain and massive hemoptysis. PE was suspected,and CT PE was performed revealing an aortic dissection involving the ascending aorta and mediastinal hemorrhage with blood compressing the right main pulmonary artery.This case not only demonstrates the variable presentation of this critical diagnosis, but also raises the question of whether undergoing TAVR increases the risk of developing an aortic dissection, and also illustrates the possible utility of CT PE in the diagnosis of this condition.https://scholarlycommons.henryford.com/merf2019caserpt/1111/thumbnail.jp

Maternity Experiences and Perceptions of Emergency Medicine Physicians

INTRODUCTION: Postpartum employment has been recognized as a significant obstacle to breastfeeding continuation rates in the general population. Multiple additional factors can influence emergency medicine (EM) physician mothers\u27 ability to continue breastfeeding upon return to work. These include the unpredictable nature of emergency room volumes and acuity, absence of protected lactation time or facilities, and varying levels of support from colleagues. This study investigated a sample of female EM physicians\u27 current perceptions and experiences regarding breastfeeding practices and identified modifiable work-place factors affecting their decision to wean. The authors hypothesized that EM physician mothers would have excellent breastfeeding initiation rates but be largely unable to maintain breastfeeding practices upon returning to work. METHODS: A 34-item survey questionnaire evaluated demographics, perceptions, and experiences with breastfeeding with a convenience sample of EM attending and resident physicians from two Michigan academic community hospitals. RESULTS: Thirty-nine surveys were completed, representing a participant response rate of 88.6%. Breastfeeding had been initiated by all respondent mothers, all of whom returned to full-time employment after delivery. Upon return to work, 15 (75%) respondents continued to exclusively breastfeed. The goal of participants was to breastfeed for an average of 7.1 months (± 4.1 months), although the average duration children were exclusively breastfed was 5.8 months (± 4.0 months). CONCLUSIONS: Based on these results, the reasons for decreased breastfeeding after return to work in an EM residency program setting are multifactorial and include some modifiable interpersonal and institutional influences. These findings support the implementation of work-place strategies and policies to promote successful breastfeeding practices among EM resident and attending physician mothers returning to work

Arterial Occlusion and Acute Deep Vein Thrombosis-Induced Acute Limb Ischemia in a COVID-19 Patient

Coronavirus disease 2019 (COVID-19) is a viral illness known to elicit a hypercoagulable state leading to a myriad of vascular pathologies. Over the course of the COVID-19 pandemic, widespread insults to the venous system have been well documented, with an increasing number of arterial events being reported. Despite the rising incidence of both pathological manifestations, these events are rare, but when present, serve as significant life threats to the patient in question. We report and discuss a case of a 69-year-old female with no thromboembolic risk factors or systemic signs of illness who presented with signs and symptoms consistent with acute limb ischemia (ALI). The patient was ultimately found to have occlusion of multiple arterial and venous vessels. She tested positive for COVID-19 despite being otherwise asymptomatic from a viral syndrome standpoint. To our knowledge, there are no reports in the medical literature of ALI - in the setting of arterial occlusion and concomitant deep vein thrombosis (DVT) - as the sole clinical manifestation in an asymptomatic patient without thrombotic risk factors who was only incidentally found to be COVID-19-positive. This case underscores the atypical manifestations and deleterious effects associated with COVID-19 and the need to have a high index of suspicion for a multitude of pathologies when facing this viral illness

Neurogenic Stunned Myocardium Following an Attempt to Pass a Drug Test

Ingestion of a large volume of free water or other hypotonic solution can cause acute hyponatremia, leading to multiorgan dysfunction. Individuals may attempt to generate a false-negative urine drug screen through increased free water consumption leading to acute hyponatremia requiring emergency medical care. We present the case of a 19-year-old male who presented to a community emergency department for altered mental status after an attempt to generate a false-negative urine drug screen. He ingested a large volume of free water and multiple detoxification solutions, causing acute hyponatremia with resultant cerebral edema and neurogenic stunned myocardium. He required extracorporeal membrane oxygenation therapy with complete recovery of neurologic and cardiac function. Acute hyponatremia from excess free water consumption is a well-documented phenomenon that all emergency providers should be aware of. Prompt identification and management of acute hyponatremia are essential to prevent potentially severe, devastating sequelae, including cerebral edema and cardiopulmonary failure.In addition, extracorporeal membrane oxygenation may be considered in patients with cardiopulmonary failure in the setting of reversible cardiomyopathy, as evidenced in our case

Three Lives At Stake: A Case of Acute Myocardial Infarction in a Patient with Twin Pregnancy

An acute myocardial infarction (AMI) is a rare complication of pregnancy. The incidence ranges between 3 to 100 per 100,000 live-births. Risk factors include common comorbidities such as smoking, hypertension, hyperlipidemia, diabetes mellitus, sedentary life-style, and obesity. Pregnancy carries additional unique AMI risk factors including advanced maternal age, preeclampsia, thrombophilia, postpartum infection/sepsis and hemorrhages. We describe the unique case of an acute ST-elevation myocardial infarction (STEMI) in a 37 year old woman at 24 weeks gestation with a dichorionic/diamniotic (DCDA) pregnancy. Through serial EKGs and echocardiography, a diagnosis was able to be made despite an atypical clinical presentation of AMI in a pregnant patient. Using a multidisciplinary approach with OB/Gyn and cardiac specialties, the patient had successful medical management and cardiac catheterization which resulted in a positive outcome as the patient recovered well and ultimately delivered healthy twins. Understanding the subtle differences of specific diagnostic and treatment pathways for AMI in pregnancy is essential to improving outcomes in both mother and fetus.https://scholarlycommons.henryford.com/merf2020caserpt/1083/thumbnail.jp

New Onset Back Pain in a Young Patient with Undiagnosed Inferior Vena Cava Atresia

We describe the emergency department (ED) and hospital course of a young male patient that came in with a chief complaint of lower back pain and was ultimately diagnosed with an acute deep venous thrombosis (DVT) precipitated by an underlying congenital abnormality of the Inferior Vena Cava (IVC). Often lower back pain in young patients can be dismissed as musculoskeletal back pain. It is for this reason, that doing a thorough review of systems and physical exam is so critical. Congenital variations or anomalies of the IVC are relatively uncommon but must be on the differential with patients presenting with back pain and symptoms involving multiple organ systems.https://scholarlycommons.henryford.com/merf2020caserpt/1096/thumbnail.jp

The Efficacy Of BE-FAST In Identifying Strokes

Introduction: By 2030, it is estimated that stroke will become the leading cause of adult disability in our country, afflicting 1 in 25 Americans. Prompt identification of stroke is essential because primary interventions such as tPA and thrombectomies, which may reduce long-term functional deficits, are extremely time sensitive. Given this, early identification through stroke screening scales such as the FAST (Face, Arms, Speech, Time) exam was developed, which have become commonplace in prehospital, emergency department (ED) and inpatient settings. Although FAST has commendable efficacy, its validity in identifying atypical or posterior circulation strokes, which often only present with balance and visual symptoms, has been challenged. To address this, a variant stroke-screening scale, BE-FAST, was developed with the inclusion of two additional criteria (Balance, Eye) to enhance stroke detection. Objective: Evaluate the sensitivity, specificity, and impact on stroke core measures with the implementation of BE-FAST in comparison to FAST in triage of a community emergency department. Methods: An observational before-and-after quality improvement (QI) initiative study was conducted for the two-month period before and after a formal BE-FAST triage screening educational module was taught to all ED clinical staff. The study sample included all patients who had stroke alerts activated based on their presenting symptoms in the ED. These patients were then divided into two groups: pre-intervention with FAST and post-intervention with BE-FAST criteria. Extensive chart review was then performed to collect the following variables: age, sex, time to stroke alert, primary identifying symptoms, time to CT and CTA, time to tPA, NIHSS score on arrival and discharge and confirmation of stroke as final discharge diagnosis. Categorical data were summarized as counts and percentages, and continuous data as means with corresponding standard deviations. Between-group mean differences were compared by calculating t-tests for independent measures and analysis of variance. Results: 155 total stroke alerts were included in the study, with 69 in the pre-intervention and 86 in the post-intervention group. Mean ages for the pre- and post-intervention groups were similar (68.3, SD=17.0 and 64.3, SD=15.5, respectively) with a preponderance of females in both groups (60.9% and 62.8%, respectively). In the first group, 29 (36.2%) had acute strokes and presented with \u3e1 FAST criteria. In the second group, 27 (31.4%) had acute strokes, with 23 (85.2%) presenting with \u3e1 FAST, and 26 (96.30%) with \u3e1 BE-FAST criteria. Although the difference was not statistically significant (p=0.35), given the deleterious consequences of delayed diagnosis, this may be of clinical significance; among the three additional strokes detected utilizing only BE symptomatology, one was given tPA. In summary, FAST rendered a sensitivity of 84% and BE-FAST 92.3%. However, this additional criterion reduced specificity from 30.0% to 16.5%. Conclusions: BE-FAST is more sensitive for identifying strokes, although at the cost of specificity. Given the significant burden of long-term deficits and the opportunity for early interventions that would otherwise be missed, this may be clinically significant, and larger trials should be conducted before widespread implementation.https://scholarlycommons.henryford.com/merf2019clinres/1024/thumbnail.jp

Comparing the Safety and Efficacy of a Rapid High-Sensitivity Cardiac Troponin I Protocol Between Hospital-Based and Free-Standing Emergency Departments

Study Objectives: Current high sensitivity cardiac troponin I (hs-cTnI) research has been conducted almost exclusively in hospital-based emergency department (HBED) settings and the translation of these protocols into free-standing emergency departments (FSED) has yet to be explored. This study compared the safety and efficacy of applying a rapid-rule out protocol using hs-cTnI for exclusion of acute myocardial infarction (AMI) in HBEDs and FSEDs. Methods: This was a secondary analysis of a randomized trial of patients evaluated for possible AMI in 9 emergency departments (ED) from July 2020 through March 2021. The trial arms included a new 0/1-hour rapid protocol using hs-cTnI versus standard care, which used a 0/3-hour protocol without reporting hs-cTnI values below the 99th percentile. The primary outcome was safe ED discharge, defined as discharge with no death or AMI within 30-days. Analysis included a mixed-effect model adjusting for demographic variables. Results: There was a statistically significant difference in safe discharges from FSEDs when comparing the standard care arm (86.2%) to the rapid rule-out protocol (95.1%). There was a statistically significant reduction in FSED length of stay with application of a rapid rule-out protocol at 3.43 hours vs. 3.97 hours using standard care. The percentage of patients who ruled-out with their initial hs-cTnI (\u3c4 ng/L) at FSEDs (74%) was also significantly larger when compared to HBEDs (54%). Conclusion: Implementation of a hs-cTnI rapid 0/1-hour protocol to evaluate for AMI in FSEDs is feasible and had greater impact on safe ED discharge and length of stay compared to HBEDs

Project #65: Reducing Door to Balloon Time in STEMI: Celebrating the EMS, ED and Cardiology QI Collaboration

Project Aim: To employ a multidisciplinary approach, engaging local emergency medical services (EMS), emergency department (ED), and cardiology teams to assure that STEMI patients in our community receive prompt, equitable, consistent, safe, and high-quality revascularization of their coronary arteries; and to deploy a variety of educational, operational and feedback tools to initiatve early prehospital EKG transmission and Cath lab activation for patients in our community suffering from ST segment elevated myocardial infarction (STEMI).https://scholarlycommons.henryford.com/qualityexpo2023/1002/thumbnail.jp

A Four-Year Multi-Center Retrospective Observational Study of Pediatric Emergency Medical Services Utilization in a Large Metropolitan Health System

Study Objectives: The COVID-19 pandemic has significantly decreased pediatric emergency department (ED) utilization. The objective of this study was to quantify the characteristics of pediatric EMS utilization both before and during the COVID-19 pandemic in a metropolitan health care system. Methods: We performed a multi-center, retrospective observational study of all pediatric ED visits between 1/1/2018 and 12/31/2021, that presented to one of nine EDs within our health system. The data were sorted by mode of arrival; children arriving to the ED via EMS, or arrival by other means. Data collection included a variety of demographic and clinical variables. We compared overall pediatric ED patients’ arrival methods as well as ED and EMS volumes by year using a binomial test with a null hypothesis that the population proportion equals 50%. Analysis compared ED mode of arrival, admission rate, and Emergency Severity Index (ESI) triage scores using chi-square tests. Results: There were 201,313 pediatric ED encounters for 118,744 unique patients meeting the inclusion criteria. There were 8,815 (4.38%) children who arrived via EMS compared to 192,498 (95.62%) children who arrived by other means (p \u3c 0.0001). Children who arrived via EMS had a higher admission rate of 22.27% (1963) compared to 5.9% (11,351, p \u3c 0.0001). ESI among children arriving via EMS was higher, with 44.3% (3847) having ESI 1 or 2 triage scores compared to 8.8% (16,790) for children arriving by other means (p \u3c 0.0001). Overall pediatric ED mortality was 0.03% (61 deaths), with 86.9% (53) of those children arriving via EMS (p \u3c 0.0001). Pediatric ED and EMS volumes in 2018 and 2019 pre-pandemic were 127,652 ED visits and 5,306 EMS visits, respectively, compared to 73,661 and 3,509 visits in 2020 and 2021. This represents a 42.3% overall reduction in pediatric ED visits (p \u3c 0.0001) and a 33.9% reduction in pediatric EMS visits (p \u3c 0.0001). Conclusion: Approximately 5% of pediatric ED encounters in our health system arrived via EMS. These children appeared to have higher acuity presentations and required inpatient services more often than children who arrived by other means. Pediatric ED and EMS encounters have decreased substantially since the onset of the pandemic