Introduction: Mushroom toxicity is an important etiology of acute liver injury in a patient with gastrointestinal symptoms. Case Report: We present the case of a male patient presenting to the emergency department (ED) with gastrointestinal distress who was placed under ED observation for elevated liver function tests. During his hospital course, it was revealed he had consumed wild mushrooms believed to be Amanita phalloides. Conclusion: While mushroom ingestion and subsequent toxicity are rare, a high index of suspicion in foraging hobbyists is essential to arriving at the correct diagnosis and directing the patient to the appropriate management.

Background: Patients with hip fractures frequently present to the emergency department (ED). Traditional methods of pain control often include the use of opioid pain medication. Fascia iliaca nerve blocks offer an alternative method to acute pain management in the ED for hip fractures. At the time of this publication, there are no readily available, cost-effective gelatin models of the surrounding fascia iliaca anatomy. Objectives: The objective was to design an accurate and cost-effective model to simulate fascia iliaca nerve block models for training emergency medicine clinicians. Discussion: A gelatin model was created to simulate the anatomy of the inguinal region in order to perform a fascia iliaca block. This fascia iliaca nerve block model aided in training of residents and attendings to become familiar with the anatomy and techniques necessary to perform this nerve block. Clinicians were able to practice ultrasound guided in-plane approach into the fascia iliaca space where they could then hydrodissect and distill anesthetic. Each model could be used several times allowing trainees multiple attempts. Conclusion: A method to create a fascia iliaca nerve block model using readily available supplies was designed to aid training of emergency medicine clinicians. We hope to improve the technique and clinician comfort-level when performing the fascia iliaca nerve block using this model.

Introduction: Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound. Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans. Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded. Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019). Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization. Conclusion: There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Neurocysticercosis is one of the most common causes of acquired epilepsy worldwide. This diagnosis is rarely considered in patients presenting to the emergency department (ED) with recurrent seizures in the United States (U.S.). This is the case of a young adult male presenting with post-ictal confusion and recurrent seizures requiring intubation for agitation and airway protection. It illustrates the need to maintain a broad differential when considering etiology of seizures in a globalized patient population.Topics:Seizure, neurocysticercosis, epilepsy, parasitic infection.

Introduction Patients presenting to the Emergency Department (ED) with a suspected peritonsillar abscess (PTA) often pose a diagnostic dilemma, as clinical impression is often unreliable and traditional diagnostic methods have multiple downsides. Bedside ultrasonography has been cited as a modality to improve the diagnosis and management of PTA. We aimed to determine the impact bedside ultrasound (US) could have in suspected PTA on ED length of stay (LOS) and hospital admission rates. Methods We performed a retrospective chart review on patients who presented to the ED with suspected ''peritonsillar abscess''. Results From a sample of 58 charts, seven had documented bedside US performed. The average ED length of stay for these seven cases was 160 minutes (range: 52 to 270 minutes). The ED length of stay for all other cases utilizing other diagnostic methods during the same time period was 293 minutes (range: 34 to 780 minutes). None of the patients who were diagnosed with US were admitted to the hospital, whereas 36.4% of patients where US was not used were admitted. Conclusion The use of bedside US in seven cases of suspected PTA had reduced LOS in the ED and none required hospital admission.

STUDY OBJECTIVE:With increasing prevalence of extended-spectrum beta-lactamase-producing enterobacteriaceae (ESBLE), more reliable identification of predictors for ESBLE urinary tract infection (UTI) in the emergency department (ED) is needed. Our objective was to evaluate risk factors and their predictive ability for ED patients with ESBLE UTI.METHODS:This was a retrospective case-control study at an urban academic medical center. Microbiology reports identified adult ED patients with positive urine cultures from 2015-2018. Inclusion criteria were diagnosis of UTI with monomicrobial enterobacteriaceae culture growth. Exclusions were cultures with carbapenemase-resistant enterobacteriaceae or urinary colonization. Collected variables included demographics, comorbidities, and recent medical history. Patient disposition, urine culture susceptibilities, presence of ESBLE, empiric antibiotics, and therapy modifications were collected. Patients were stratified based on ESBLE status and analyzed via descriptive statistics. The data were divided into 2 parts: the first used to identify possible predictors of ESBLE UTI and the second used to validate an additive scoring system.RESULTS:Of 466 patients, 16.3% had ESBLE urine culture growth and 83.7% did not; 39.5% of ESBLE patients required antibiotic therapy modification, as compared to 6.4% of ESBLE negative patients (odds ratio [OR] 9.5; confidence interval [CI] 8.9-10.1). Independent predictors of ESBLE UTI were IV antibiotics within 1 year (OR 5.4; CI 2.1-12.8), surgery within 90 days (OR 6.4; CI 1.5-27.8), and current refractory UTI (OR 8.5; CI 2.0-36.6).CONCLUSION:Independent predictors of ESBLE UTI in emergency department patients included IV antibiotics within 1 year, surgery within 90 days, and current refractory UTI.

Objective: The primary purpose of this study was to identify the most common drug-drug interactions 9DDI'S) in patients prescribed medications upon discharge from the emergency department. Methods: We conducted a respective chart review of patients discharged home with a prescription from an academic emergency department. The study periodwas fromAugust 1, 2015 to August 31, 2015. Patientswill be excluded if they meet the following criteria: age under 20 years; discharge home without a prescription; inpatient hospital admission; transfer to another inpatient facility; or sign out against medical advice. The primary endpoint is the identification and characterization of drug-drug interactions caused by discharge prescriptions written by the treating physician. Results: A total of 500 patient charts were included, with 38% having at least one DDI. Overall, there were 429 DDIs among 858 prescriptions written. 15.6% (n=67) of the DDI's were classified as B, no modification of therapy needed. 60% (n =260) of the DDIs were risk-rating category C, requiring monitoring of therapy. 22% (n = 95) of the DDI's identified were category D, which are consider modification of therapy. Lastly, we identified 1.6% (n=7) category X DDI's. The top 3most commonly associated drugswere oxycodone/acetaminophen, ibuprofen, and ciprofloxacin. Conclusion: DDIs are occurring upon discharge from a large, urban, tertiary care, academic medical center. Many of the DDI's identified do not require any modification to therapy. However, 23.6% of identified DDI's required modification or were contraindicated. A majority of the category X drug interactions involved QT prolongation. (c) 2019 Published by Elsevier Inc.

Background: The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency. Methods: The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated. Results: In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year. Conclusions: Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

History of present illness: A 55-year-old male presented to the emergency department with a chief complaint of right arm pain. Five days prior to arrival, he attempted to lift himself up on his van and experienced what he described as a “rubber band snapping” in his right arm. He reported severe pain at the time that persisted but lessened in severity. Additionally, he reported increasing bruising over the proximal right arm. He had no history of prior right arm or shoulder injury. Significant findings: Physical exam was significant for ecchymosis and mild swelling of the right bicep. When the right arm was flexed at the elbow, a prominent mass was visible and palpable over the right bicep. Right upper extremity strength was 4/5 with flexion at the elbow. Discussion: The biceps brachii muscle is comprised of a long and short head, which share a common attachment at the bicipital tuberosity on the radius. The short head originates from the coracoid process of the scapula and the long head originates from the supraglenoid tubercle.1 Biceps tendon rupture has been found to occur at a rate of 0.53/100,000 over five years, and is three times more likely to occur in men than women.2 Risk factors for biceps tendon rupture include male sex, old age, increased body mass index, smoking, and pre-existing shoulder pathology.3,4 Diagnosis of biceps tendon rupture is typically a clinical diagnosis utilizing inspection and palpation as well as special testing such as the Speed’s and/or Yergason’s tests. Ultrasound may be used to aid in diagnosis; in full-thickness tears, ultrasound was found to have a sensitivity of 88% and a specificity of 98%. However, in partial thickness tears ultrasound has a sensitivity of 27% and a specificity of 100%.5 Often considered the gold standard in diagnosis, MRI has been found to have a sensitivity of only 67% and specificity of 98% in detecting complete tears6. Treatment initially consists of rest, ice, compression, and a short course of non-steroidal anti-inflammatory drugs. Follow up with an orthopedic surgeon is recommended in two to four weeks to determine operative versus non-operative management.7

Background: Apical hypertrophic cardiomyopathy is a rare, complex phenotypic variant of the classically taught hypertrophic cardiomyopathy. It is highly variable in its pathophysiology as well as its clinical course, spanning the spectrum from a healthy asymptomatic lifestyle to sudden cardiac death and severe diastolic dysfunction. The hallmark electrocardiographic findings of unusually large T-wave inversions, in conjunction with the most common presenting symptom being chest pain, makes this disease entity concerning in the emergency department (ED) setting. Case Report: A 61-year-old man with a history of hypertension presented to the ED with chest pain. His electrocardiogram exhibited a biphasic T wave in lead V2 with ST depressions in leads V3-V6 with deep symmetrical T-wave inversions in these leads as well. His troponin was negative and the patient was taken for cardiac catheterization. Catheterization revealed no coronary artery disease; however, it revealed a "spade like'' filling pattern of the left ventricle, suggestive of an apical variant of hypertrophic cardiomyopathy. Subsequent cardiac magnetic resonance imaging confirmed the diagnosis of apical hypertrophic cardiomyopathy and the patient was started on a beta-blocker and discharged with cardiology follow-up. Why Should an Emergency Physician Be Aware of This?: Electrocardiographic interpretation is a critical skill of the emergency physician. Awareness of the syndrome and its specific electrocardiogram findings may help facilitate further testing that will aid in timely diagnosis and interventions. (C) 2018 Elsevier Inc. All rights reserved.

History of present illness: A 57-year-old male presented 24 hours after punching another individual in the mouth and injuring his right hand. He complained of pain and decreased range of motion in his 4th digit. On exam, the patient had a 1 cm laceration to his right 4th metacarpophalangeal joint with soft tissue swelling and limited extension of the digit against resistance. Significant findings: The video shows a water bath ultrasound of the right 4th digit, demonstrating soft tissue swelling with a hypoechoic region along the tendon consistent with edema and tendon disruption (see video and annotated still image). Discussion: Hand extensor tendon injuries can be caused by laceration, trauma, or overuse.1 Extensor tendon injuries are classified into eight zones.2 This patient suffered a Zone V partial tendon injury, commonly termed a “fight bite.” Management of tendon injuries is dependent on: partial vs full, closed vs open, and injury location.3,4 Closed tendon injuries require a volar extension splint with hand surgery follow-up within one week. Open tendon injuries involving >50% tendon width can be repaired in the emergency department, though some will require delayed repair.4 Ruptures involving <50% of tendon width should be placed in a volar extension splint, whereas ruptures involving >50% of tendon width should be sutured.3 Injuries to Zones II-IV and Zone VI may be repaired in the emergency department.4 However, injuries to other zones, the thumb, open fractures, neurovascular compromise, grossly contaminated wounds, or immunocompromised patients should be referred to a hand surgeon.5 “Fight bite” injuries should be treated with antibiotics and hand surgery consult for possible operative intervention.6After a normal X-ray, a bedside water-bath ultrasound was performed, revealing a Zone V extensor tendon rupture. The patient received tetanus prophylaxis, IV antibiotics, was splinted and admitted to the hand surgery service for operative washout of the wound and delayed tendon repair. Topics: Water bath ultrasound, tendon laceration, extensor tendon injury, fight bite, hand injury, orthopedics.

History of present illness: A 56-year-old male, with a history of hypertension, diabetes, and dyslipidemia, presented with chest pain, fever, and abdominal pain associated with diarrhea, one day post colonoscopy, for which an electrocardiogram (ECG) was done. On further review of history, the patient reported a syncopal episode 2 monthprior. Additionally, he reports a brother who died of sudden cardiac death (SCD) at the age 50. Significant findings: ECG shows an incomplete right bundle branch block (blue arrow) with coved ST segment elevation and an inverted T wave in V1 (red arrow) and ST segment elevation in V2 (black arrow). Discussion: Brugada syndrome is a rare autosomal dominant disease with mutations in the cardiac sodium channel. It is highly associated with ventricular fibrillation and sudden cardiac death (SCD) in predominately middle-aged males.1 The diagnosis is based on a particular ECG pattern described by the Brugada brothers in 1992.2 There are 3 types of Brugada patterns. Our patient’s ECG was consistent with type 1, which is diagnostic and is characterized by a coved ST segment elevation greater than 2mm followed by a negative T wave in the precordial leads.3 Other types include type 2, which shows a saddle-back ST segment elevation with a J-wave greater than 2mm followed by a positive or biphasic T wave, and type 3, which shows ST elevation less than 2 mm in either coved or saddle-back type T wave.4 Patients with Brugada syndrome often present with syncope, non-sustained ventricular tachycardia, atrial fibrillation, or SCD, with a family history of similar episodes. The presence of fever, alcohol intake, sodium channel blockers, cocaine use, and electrolyte imbalances can significantly increase the incidence of arrhythmia.1 The risk of cardiac events in patients with type 1 Brugada and syncope is 1.9% per year and 7.7% per year in those with aborted SCD.3 An implantable cardiac defibrillator (ICD) is the main treatment for symptomatic patients. Those who are asymptomatic or those with type 2 or 3 morphology should undergo further genetic testing and risk stratification for ICD placement.1 Our patient had a negative cardiac catheterization but with his ECG pattern along with his history of syncope and family history of SCD, he was diagnosed with type 1 Brugada syndrome and received an ICD. Topics: EKG, ECG, cardiology, Brugada, arrhythmia

History of present illness: 70-year-old male with a history ventricular arrhythmia, AICD (automated implantable cardioverter defibrillator), coronary artery disease and cardiac stents presented to the Emergency Department after three AICD discharges with dyspnea but no chest pain. During triage, he was found to have an irregular radial pulse and was placed on a cardiac monitor. Significant findings: The patient was found to be in a polymorphic ventricular tachycardia; he was alert, awake and asymptomatic. A rhythm strip showed a wide complex tachycardia with the QRS complex varying in amplitude around the isoelectric line consistent with Torsades de Pointes. Discussion: Torsades de Pointes (TdP) is a specific type of polymorphic ventricular tachycardia. The arrhythmia’s characteristic morphology consists of the QRS complex “twisting” around the isoelectric line with gradual variation of the amplitude, reflecting its literal translation of “twisting of the points.”1 This arrhythmia occurs in the context of prolonged QT. The most common form of acquired QT prolongation is medication induced. Common causes include antiarrhythmics, antipsychotics, antiemetics, and antibiotics.2 Patient specific risk factors include female sex, bradycardia, hypokalemia, hypomagnesemia, hypocalcemia, hypothermia and heart disease.3 In the setting of prolonged QT, the repolarization phase is extended. TdP is initiated when a PVC (premature ventricular contraction) occurs during this repolarization, known as an ‘R on T’ phenomenon. TdP is often asymptomatic and self-limited. The danger in TdP is its potential to deteriorate into ventricular fibrillation. A mainstay of management of TdP is prevention of risk factors when possible.4 Unstable patients should be treated with synchronized cardioversion. Magnesium sulfate should be administered in all cases of TdP.1 If a patient is not responsive to magnesium, consider isoproterenol, amiodarone, and overdrive pacing. Since this patient was asymptomatic, he was given 2gm of magnesium sulfate and placed on an amiodarone infusion, after which Tdp terminated with a resulting sinus rhythm. AICD interrogation showed multiple episodes of ventricular fibrillation. The patient was admitted for further management and to determine why his AICD was not functioning properly. Topics: EKG, ECG, cardiology, ventricular tachycardia, arrhythmia, Torsades de Pointes

History of present illness: A 77-year-old female presented to the emergency department after being found down at home, last seen normal 7 ½ hours prior to arrival. Patient had a history of hypertension, congestive heart failure, atrial fibrillation and breast cancer status post chemotherapy/radiation and lumpectomy. Physical exam showed right gaze preference, left facial droop and tongue deviation and flaccid left hemiplegia. Significant findings: A non-contrast computed tomography (CT) scan showed a hyperdensity along the right middle cerebral artery (MCA) consistent with acute thrombus. The red arrow highlights the hyperdensity in the annotated image. Discussion: The dense MCA sign can serve as an important tool in the diagnosis of acute stroke. It typically appears before other signs of infarct are apparent on CT imaging, and identifies an intracranial large artery occlusion and corresponding infarct, in the correct clinical setting.1 Calcifications in the same area of the brain could be mistaken for an MCA sign, but this sign carries a high specificity (95%) and lower sensitivity (52%) for arterial obstruction in ischemic stroke.2 Early identification allows for a wider array of treatment options for a patient with an ischemic stroke, including intra-venous or intra-arterial thrombolysis and mechanical thrombectomy. This patient was subsequently taken for mechanical thrombectomy. Mechanical thrombectomy was chosen for this patient because the resources were available, and recent clinical trials have shown that newer types of mechanical thrombectomy have a positive functional outcome in patients with an ischemic stroke from an intracranial large artery occlusion, as compared to intravenous tissue plasminogen activator (tPa) alone.3,4,5,6 In facilities lacking the capability for mechanical thrombectomy, treatment considerations include rapid transfer to a facility with capability, or proceeding with intravenous tPa. After intervention, this patient had residual left sided deficits and dysarthria that were improved from presentation. She had an uncomplicated hospital course and was discharged to acute rehabilitation.

History of present illness: A 28-year-old male presents to emergency department with a chief complaint of dysuria over the past seven days associated with a new penile lesion over the same period. He reports sexual activity with “many men and women” without condom use. His review of system is otherwise negative. Significant findings: Physical examination revealed a non-tender, erythematous lesion on the glans penis, two similar adjacent satellite lesions, as well as tender inguinal lymphadenopathy. No penile discharge was noted. Discussion: Syphilis is a sexually transmitted disease caused by Treponema pallidum. The early stage of the infection consists of three phases – primary syphilis, secondary syphilis and early latent syphilis. The late stage occurs amongst untreated patients, leading to asymptomatic chronic latent disease.2 The feared complication of latent disease is progression to tertiary syphilis, which may occur decades later and includes major cutaneous, musculoskeletal, cardiovascular, and neurological complications.1 Primary syphilis infection manifests as a chancre, a localized, typically painless skin lesion at the site of inoculation. The classic lesion forms a 1-2-centimeter ulcer with a raised, indurated margin commonly with associated moderate regional lymphadenopathy. Chancres are self-limited and heal within six weeks without treatment.2,5 Diagnosis can be made with nontreponemal tests (which are nonspecific) and treponemal tests (which are more complex and expensive, but specific). Nontreponemal tests include the rapid plasma regain (RPR) and venereal disease research laboratory (VDRL). The treponemal test of choice is the fluorescent treponemal antibody absorption (FTA-ABS). Darkfield microscopy in combination with direct fluorescent antibody testing can be used to identify the organism.1,5 The preferred treatment for early syphilis is a single dose of 2.4 million units of intramuscular penicillin G.1,3,4 Our patient was given this treatment, along with empiric coverage for gonorrhea and chlamydia co-infection with ceftriaxone and azithromycin. His RPR and FTA testing was positive, as was his chlamydia DNA PCR.