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Medical simulation is a widely used training modality that is particularly useful for procedures that are technically difficult or rare. The use of simulations for educational purposes has increased dramatically over the years, with most emergency medicine (EM) programs primarily using mannequin-based simulations to teach medical students and residents. As an alternative to using mannequin, we built a 3D printed models for practicing invasive procedures. Repeated simulations may help further increase comfort levels in performing an emergency department (ED) thoracotomy in particular, and perhaps this can be extrapolated to all invasive procedures. Using this model, a simulation training conducted with EM residents at an inner city teaching hospital showed improved confidence. A total of 21 residents participated in each of the three surveys [(1) initially, (2) after watching the educational video, and (3) after participating in the simulation]. Their comfort levels increased from baseline after watching the educational video (9.5%). The comfort level further improved from baseline after performing the hands on simulation (71.4%).

Synthetic cannabinoids Receptor Agonist (SCRA) intoxication presents with various medical and psychiatric symptoms. The products are sold as K2 or Spice. The symptoms range from agitation, altered mental status (AMS), lethargy, paranoid behavior, psychosis and seizures. In some cases, brief psychiatric or inpatient medicine admission was required for stabilization. Some patients seem to stay longer for observation in the ED. These patients worsen the already problematic ED crowding. To assess K2-related ED presentation, length of stay in the ED and types of disposition over a 5 year period. A retrospective chart review of patients who presented with K2 intoxication. Charts were reviewed from January 1, 2012 until December 31st, 2016 excluding 2016. Demographics, age, gender, past psychiatric illness and other substance abuse history were reviewed. A total of 1405 patients were seen for K2-related ED visits from January 1, 2012 until December 31st, 2016 of which 1279 patients (91%) were male and 126 patients (9%) were female. One hundred thirty nine patients (9.9%) were hospitalized and 1266 patients (90.1%) were either discharged or left from the ED. Twenty-eight (2.0%) stayed more than 16 hours in the ED. Of the 53 patients, whose urine the showed benzodiazepine or opiates 36 patients stayed more than 6 hours in the ED. Most patients with K2 use were male (91%) between the ages of 19 and 50 years (76.4%). There was a surge in K2-related presentation in 2015, particularly in the months of April until November. In addition, K2-related intoxication led to prolonged ED stay, which could affect the ED crowding phenomenon. A concerted effort from public pressure and legislative measures led to a reduction of K2-related visits to the ED.

Background.Computerized electrocardiogram (ECG) analysis has been of tremendous help for noncardiologists, but can we rely on it? The importance of ST depression and T wave inversions in lead aVL has not been emphasized and not well recognized across all specialties.Objective.This study’s goal was to analyze if there is a discrepancy of interpretation by physicians from different specialties and a computer-generated ECG reading in regard to a TWI in lead aVL.Methods.In this multidisciplinary prospective study, a single ECG with isolated TWI in lead aVL that was interpreted by the computer as normal was given to all participants to interpret in writing. The readings by all physicians were compared by level of education and by specialty to one another and to the computer interpretation.Results.A total of 191 physicians participated in the study. Of the 191 physicians 48 (25.1%) identified and 143 (74.9%) did not identify the isolated TWI in lead aVL.Conclusion.Our study demonstrated that 74.9% did not recognize the abnormality. New and subtle ECG findings should be emphasized in their training so as not to miss significant findings that could cause morbidity and mortality.

Background In the past couple of years, there has been an outbreak of synthetic cannabinoid (SC) use in major cities in the United States. Patients can present with various symptoms affecting the central nervous and cardiovascular systems. The effects of endocannabinoid on contractility and Ca 2+ signaling have been shown through both cannabinoid receptors and a direct effect on ion channels. These effects result in abnormalities in ionotropy, chronotropy, and conduction. Case Report Here we report on two cases of SC abuse and abnormalities in the cardiovascular system. These cases raise concerns about the adverse effects of SCs and the possibility of QTc prolongation and subsequent complications when using antipsychotic medication in the presence of SC abuse. Why Should an Emergency Physician be Aware of This? Given the rise in SC use and the potential effect on the cardiovascular system, physicians need to be mindful of potential cardiac complications, such as QTc prolongation and torsade de pointe, especially when administering medications that have the potential to cause QTc prolongation.

Background. Bacterial meningitis is a life-threatening medical emergency that requires urgent diagnosis and treatment. Diagnosis is infrequently missed if the patient presents with the classic symptoms of fever, headache, rash, nuchal rigidity, or Kernig or Brudzinski sign. However, it may be less obvious in neonates, elderly, or immunocompromised patients. Meningitis which presents as isolated torticollis, without any other signs or symptoms, is exceedingly rare.Objective. To identify an abnormal presentation of meningitis in an adult immunocompromised patient.Case Report. We present a case of an adult diabetic male who presented multiple times to the ED with complaint of isolated torticollis, who ultimately was diagnosed with bacterial meningitis.Conclusion. We propose that in the absence of sufficient explanation for acute painful torticollis in an immunocompromised adult patient, further evaluation, possibly including a lumbar puncture may be warranted.

Background Angioedema secondary to angiotensin-converting enzyme inhibitors (ACEI) is a commonly encountered problem in the Emergency Department (ED). The treatment of ACEI-induced edema with conventional methods such as epinephrine, steroids, and antihistamines is usually not effective. There is limited experience using bradykinin receptor blockers and fresh frozen plasma (FFP) as a treatment modality for ACEI-induced angioedema. Objective To emphasize alternative treatment option for ACEI-induced angioedema in the ED. Case Reports We report a case series of progressive and refractory presumed ACEI-induced angioedema that all improved in temporal association with administration of FFP, with a brief review of the literature. Conclusion There was a temporal association between the administration of FFP and improvement in angioedema in seven cases of presumed ACEI-induced angioedema that were refractory to antihistamines, corticosteroids, and epinephrine.

Increased anterior chamber pressure also known as intraocular pressure can result from conditions such as glaucoma and trauma. The pressure in the anterior chamber is measured using tonometer. Measurement of the intraocular pressure is essential, as it requires immediate medical attention to alleviate pain and to avoid temporary or permanent damage to intraocular structures. Bedside ocular ultrasound (US) has gained popularity in recent years. It has been used to assess intracranial pressure via optic nerve sheath diameter (ONSD) and evaluate retinal detachment, vitreous hemorrhage, or pupillary reflex in a trauma patient. We report 2 cases of patients with glaucoma and a case of a patient with trauma to the eye with swelling. Anterior chamber depth measurement was conducted and compared with measurements of intraocular pressure (IOP) using a tonometer.

Background. Angioneurotic edema is a life-threatening medical emergency that requires urgent diagnosis and treatment. Haloperidol is in the butyrophenone class of antipsychotic medications. Acute anaphylaxis to Haloperidol is very rare and no cases have been reported in literature.Objective. To report the association of life-threatening angioneurotic edema with intramuscular Haloperidol.Case Report. We present a case of an adult with no known allergies in whom angioneurotic edema with tongue swelling and protrusion developed after the administration of a single IM dose of Haloperidol.Conclusion. We propose angioneurotic edema in a rare side effect of Haloperidol. The onset of the symptoms is abrupt, but it may take 12–36 hours to resolve completely. Therefore patient should be monitored for 12–36 hrs.