Subacute Presentation of Central Cord Syndrome Resulting from Vertebral Osteomyelitis and Discitis: A Case Report

Introduction: Central cord syndrome (CCS) is a clinical syndrome of motor weakness and sensory changes. While CCS is most often associated with traumatic events. There have been few documented cases being caused by abscesses resulting from osteomyelitis.Case Report: A 56-year-old male presented to a regional trauma center complaining of excruciating neck and bilateral upper extremity pain. Computed tomography of the cervical and thoracic regions revealed severe discitis and osteomyelitis of the fourth and fifth cervical (C4-C5) with near-complete destruction of the C4 vertebral body, as well as anterolisthesis of C4 on C5 causing compression of the central canal. Empiric intravenous (IV) antibiotic therapy with ampicillin/sulbactam and vancomycin was initiated, and drainage of the abscess was scheduled. After the patient refused surgery, he was planned to be transferred to a skilled nursing facility to receive a six-week course of IV vancomycin therapy. A month later, patient returned to emergency department with the same complaint due to non-compliance with antibiotic therapy.Discussion: Delayed diagnosis and treatment of osteomyelitis can result in devastating neurological sequelae, and literature supports immediate surgical debridement. Although past evidence has suggested surgical intervention in similar patients with presence of abscesses, this case may suggest that antibiotic treatment may be an alternative approach to the management of CCS due to an infectious etiology. However, the patient had been non-compliant with medication, so it is unknown whether there was definite resolution of the condition.Conclusion: In patients presenting with non-traumatic central cord syndrome, it is vital to identify risk factors for infection in a thoroughly obtained patient history, as well as to maintain a low threshold for diagnostic imaging

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation

Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock.Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma.Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma  (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0).Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock

Variation in Trauma Team Response Fees in United States Trauma Centers

Objectives: Investigate the variation of the trauma team response fee (TTRF) among all levels of Trauma Centers (TC) Level I-IV, in different geographic regions in the U.S. (Midwest, West, South, Northeast U.S.).Background: Investigate Hospital Medical Directors (HMD) and Trauma Medical Directors (TMD) knowledge of TTRF dollar amount in their institution.Methods:Setting 525 American College of Surgeons verified trauma centers (TC) in the U.S. Level I-IV TCs.TC’s in the continental U.S including Alaska and Hawaii.Data Collection Cross-sectional convenience sample. Online survey development cloud-based software, Survey Monkey.Responses from October 8, 2019 through March 11, 2020.Results: True costs of TTRF’s in the U.S remains elusive due to inadequate data.  TTRF’s were higher in level II TC’s in the West compared to Level I’s. No statistically significant difference in TTRF’s despite geographical and cost of living differences. 41.3% of HMD are aware of dollar amount of TTRF’s. 56.5% of TMD are aware of dollar amount of TTRF’s.Conclusion: Transparency in trauma costs is not common practice.Trauma Centers attempts to balance responsible financial billing and maintaining viability is an ongoing concern as trauma costs rise.Limited options are available to offset growing costs.Regulatory and public awareness of these increasing TTRF’s has resulted in a push for transparency Federal and state financial support is needed to aid TC’s to offset growing trauma care costs.Vigilant efforts are needed in patient advocacy to ensure all patients receive quality trauma care with justified associated charges

A role of point-of-care ultrasound in the emergency department diagnosis of vision loss due to traumatic cataract

Abstract Background Ocular complaints, including acute or subacute vision loss, are commonly encountered in emergency departments (ED). These potentially time-sensitive complaints are difficult to diagnose and evaluate without adequate, specialized equipment and expertise. Additionally, a thorough evaluation often requires a more extensive and specialized physical exam, imaging, and ophthalmologic consultation, all of which may not be readily available in the acute setting. Case presentation This case report presented a patient in the emergency department with the chief complaint of vision loss. Point-of-care ultrasound (POCUS) using the 10-MHz-linear-array probe, in the ocular setting, demonstrated calcification of the lens, a finding consistent with cataract in the right eye. Conclusions The use of POCUS can expedite the accurate identification of vision threatening pathology, such as cataracts, and streamline ED disposition and plan of care

A Rare Cause of Chest Pain Identified on Point-of-care Echocardiography: A Case Report

Introduction: Cardiac masses are a rare cause of chest pain. They can often be missed on a chest radiograph performed to evaluate non-specific chest pain and are not readily evaluated with traditional laboratory testing. However, these masses can be visualized with point-of-care ultrasound.Case Report: We present a case of a 19-year-old female presenting with intermittent chest pain, palpitations, and weakness present for two months. The patient had previously been evaluated at our emergency department one week earlier and was diagnosed with anxiety before being discharged. Besides a tachycardic and labile heart rate, physical examination and laboratory testing were unremarkable. Point-of-care cardiac echocardiography subsequently demonstrated findings concerning for a cardiac mass.Conclusion: Cardiac masses are a rare cause of chest pain and palpitations that are easily missed. The advent of point-of-care ultrasonography has afforded us the ability to rapidly assess for structural and functional cardiac abnormalities at bedside, and incorporation of this tool into the evaluation of patients with chest pain offers the ability to detect these rare pathologies

Novel Application of Balloon Tamponade in Management of Acute Lower Gastrointestinal Hemorrhage

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital

Coccidioidomycosis of the Vocal Cords Presenting in Sepsis: A Case Report and Literature Review

Coccidioidomycosis is a predominantly pulmonary disease caused by species of Coccidioides, a fungus endemic to the American Southwest. Most cases involve exclusively pulmonary manifestations while less than one percent present with disseminated infection, usually with meningeal or skin involvement. In this case, a patient with a history of odynophagia, sore throat, productive cough, weight loss, and abnormalities on chest radiograph presented with sepsis and diabetic ketoacidosis. During admission, the patient underwent bronchoscopy with resulting tissue and bronchoalveolar lavage samples positive for Coccidioides immitis, later supported by confirmatory serum studies. This case illustrates a rare presentation of vocal fold involvement without direct invasion from a continuous site and highlights the importance of a high index of suspicion for disseminated coccidioidomycosis with prompt antifungal treatment in order to avoid the very high morbidity and mortality in such cases

The Psychological Impact of COVID-19 on Hospital Staff

Introduction: The coronavirus 2019 (COVID-19) pandemic has created a mental health crisis among hospital staff who have been mentally and physically exhausted by uncertainty and unexpected stressors. However, the mental health challenges and complexities faced by hospital staff in the United States has not been fully elucidated. To address this gap, we conducted this study to examine the prevalence and correlates of depression and anxiety among hospital staff in light of the COVID-19 pandemic.Methods: The design is a single-center, cross-sectional, online survey evaluating depression and anxiety among all hospital employees (n = 3,500) at a safety-net hospital with a moderate cumulative COVID-19 hospitalization rate between April 30–May 22, 2020. We assessed depression with the Patient Health Questionnaire-9. Anxiety was measured with the Generalized Anxiety Disorder-7 scale. Logistic regression analyses were calculated to identify associations with depression and anxiety.Results: Of 3,500 hospital employees, 1,246 (36%) responded to the survey. We included 1,232 individuals in the final analysis. Overall, psychological distress was common among the respondents: 21% and 33% of staff reported significant depression and anxiety, respectively, while 46% experienced overwhelming stress due to COVID-19. Notably, staff members overwhelmed by the stress of COVID-19 were seven and nine times more likely to suffer from depression and anxiety, respectively. In addition to stress, individuals with six to nine years of work experience were two times more likely to report moderate or severe depression compared to those with 10 or more years of work experience. Moreover, ancillary staff with direct patient contact (odds ratio [OR] 8.9, confidence interval (CI), 1.46, 173.03) as well as administrative and ancillary staff with indirect patient contact (OR 5.9, CI, 1.06, 111.01) were more likely to be depressed than physicians and advanced providers.Conclusion: We found that a considerable proportion of staff were suffering from psychological distress. COVID-19-associated depression and anxiety was widespread among hospital staff even in settings with comparatively lower COVID-19 hospitalization rates. Ancillary staff, administrative staff, staff with less job experience, and staff overwhelmed by the stress of COVID-19 are particularly susceptible to negative mental health outcomes. These findings will help inform hospital policymakers on best practices to develop interventions to reduce the mental health burden associated with COVID-19 in vulnerable hospital staff

Subacute Presentation of Central Cord Syndrome Resulting from Vertebral Osteomyelitis and Discitis: A Case Report

Introduction: Central cord syndrome (CCS) is a clinical syndrome of motor weakness and sensory changes. While CCS is most often associated with traumatic events. There have been few documented cases being caused by abscesses resulting from osteomyelitis.Case Report: A 56-year-old male presented to a regional trauma center complaining of excruciating neck and bilateral upper extremity pain. Computed tomography of the cervical and thoracic regions revealed severe discitis and osteomyelitis of the fourth and fifth cervical (C4-C5) with near-complete destruction of the C4 vertebral body, as well as anterolisthesis of C4 on C5 causing compression of the central canal. Empiric intravenous (IV) antibiotic therapy with ampicillin/sulbactam and vancomycin was initiated, and drainage of the abscess was scheduled. After the patient refused surgery, he was planned to be transferred to a skilled nursing facility to receive a six-week course of IV vancomycin therapy. A month later, patient returned to emergency department with the same complaint due to non-compliance with antibiotic therapy.Discussion: Delayed diagnosis and treatment of osteomyelitis can result in devastating neurological sequelae, and literature supports immediate surgical debridement. Although past evidence has suggested surgical intervention in similar patients with presence of abscesses, this case may suggest that antibiotic treatment may be an alternative approach to the management of CCS due to an infectious etiology. However, the patient had been non-compliant with medication, so it is unknown whether there was definite resolution of the condition.Conclusion: In patients presenting with non-traumatic central cord syndrome, it is vital to identify risk factors for infection in a thoroughly obtained patient history, as well as to maintain a low threshold for diagnostic imaging

This Article Corrects: "Subacute Presentation of Central Cord Syndrome Resulting from Vertebral Osteomyelitis and Discitis: A Case Report"

Introduction: Central cord syndrome (CCS) is a clinical syndrome of motor weakness and sensory changes. While CCS is most often associated with traumatic events. There have been few documented cases being caused by abscesses resulting from osteomyelitis.Case Report: A 56-year-old male presented to a regional trauma center complaining of excruciating neck and bilateral upper extremity pain. Computed tomography of the cervical and thoracic regions revealed severe discitis and osteomyelitis of the fourth and fifth cervical (C4-C5) with near-complete destruction of the C4 vertebral body, as well as anterolisthesis of C4 on C5 causing compression of the central canal. Empiric intravenous (IV) antibiotic therapy with ampicillin/sulbactam and vancomycin was initiated, and drainage of the abscess was scheduled. After the patient refused surgery, he was planned to be transferred to a skilled nursing facility to receive a six-week course of IV vancomycin therapy. A month later, patient returned to emergency department with the same complaint due to non-compliance with antibiotic therapy.Discussion: Delayed diagnosis and treatment of osteomyelitis can result in devastating neurological sequelae, and literature supports immediate surgical debridement. Although past evidence has suggested surgical intervention in similar patients with presence of abscesses, this case may suggest that antibiotic treatment may be an alternative approach to the management of CCS due to an infectious etiology. However, the patient had been non-compliant with medication, so it is unknown whether there was definite resolution of the condition.Conclusion: In patients presenting with non-traumatic central cord syndrome, it is vital to identify risk factors for infection in a thoroughly obtained patient history, as well as to maintain a low threshold for diagnostic imaging