Publications by authors named "Brit Long"

299 Publications

A first trimester pregnancy with cerebrovascular accident treated with thrombolytic therapy: A case report.

Am J Emerg Med 2021 Apr 13. Epub 2021 Apr 13.

Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.

Pregnant patients are at increased risk of cerebrovascular accident due to the prothrombotic state of pregnancy. This risk is highest in those with pre-eclampsia and eclampsia as well as those of Asian descent. Despite this increased risk, pregnancy was an exclusion criterion for major stroke intervention trials. As a result, there are significant challenges concerning the management of this unique patient population. We describe a case of an early first trimester cerebrovascular accident treated with systemic thrombolysis.
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http://dx.doi.org/10.1016/j.ajem.2021.04.021DOI Listing
April 2021

Response to: "POCUS to Confirm Intubation in a Trauma Setting".

West J Emerg Med 2020 Dec 16;22(2):400. Epub 2020 Dec 16.

Brooke Army Medical Center, Department of Emergency Medicine, San Antonio, Texas.

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http://dx.doi.org/10.5811/westjem.2020.9.50017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972358PMC
December 2020

Is a Lumbar Puncture Required to Rule Out Atraumatic Subarachnoid Hemorrhage in Emergency Department Patients With Headache and Normal Brain Computed Tomography More Than Six Hours After Symptom Onset?

J Emerg Med 2021 Apr 7. Epub 2021 Apr 7.

Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.

Background: Atraumatic subarachnoid hemorrhage (SAH) is a deadly condition that most commonly presents as acute, severe headache. Controversy exists concerning evaluation of SAH based on the time from onset of symptoms, specifically if the headache occurred > 6 h prior to patient presentation.

Clinical Question: Do patients undergoing evaluation for atraumatic SAH who have a negative computed tomography (CT) scan of the head obtained more than 6 h after symptom onset require a subsequent lumbar puncture to rule out the diagnosis?

Evidence Review: Studies retrieved included a retrospective cohort study, two prospective cohort studies, and a case-control study. These studies provide estimates of the diagnostic accuracy of head CT imaging obtained > 6 h from symptom onset and diagnostic test characteristics of subsequent lumbar puncture.

Conclusion: The probability of SAH above which emergency clinicians should perform a lumbar puncture is 1.0%. This threshold is essentially the same as the estimated probability of SAH in patients with a negative head CT obtained more than 6 h from symptom onset. Emergency physicians might reasonably decide to either perform or forego this procedure. Consequently, we contend that the decision whether to perform lumbar puncture in these instances is an excellent candidate for shared decision-making.
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http://dx.doi.org/10.1016/j.jemermed.2021.01.039DOI Listing
April 2021

Pulmonary arterial hypertension in the emergency department: A focus on medication management.

Am J Emerg Med 2021 Mar 26;47:101-108. Epub 2021 Mar 26.

University of Kentucky HealthCare, Lexington, KY, 40536, United States of America.

Pulmonary arterial hypertension (PAH) is a chronic progressive incurable condition associated with a high degree of morbidity and mortality. With over five drug classes FDA approved in the last decade, the significant advancements in the pharmacologic management of PAH has improved long-term outcomes. Drug therapies have been developed to directly target the underlying pathogenesis of PAH including phosphodiesterase type-5 inhibitors (PDE-5i), endothelin-receptor antagonists (ERAs), guanylyl-cyclase inhibitors, prostacyclin analogues, and prostacyclin receptor agonists. Although these agents offer remarkable benefits, there are significant challenges with their use such as complexities in medication dosing, administration, and adverse effects. Given these consequences, PAH medications are classified as high-risk, and the transitions of care process to and from the hospital setting are a vulnerable area for medication errors in this population. Thus, it is crucial for the emergency department provider to appropriately identify, manage, and triage these patients through close collaboration with a multidisciplinary team to ensure safe and effective medication management for PAH patients in the acute care setting.
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http://dx.doi.org/10.1016/j.ajem.2021.03.072DOI Listing
March 2021

Symptomatic Emergency Department Patients Should Undergo Empirical Therapy for Gonorrhea/Chlamydia Regardless of Testing.

Ann Emerg Med 2021 04;77(4):410-411

Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX.

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http://dx.doi.org/10.1016/j.annemergmed.2020.07.006DOI Listing
April 2021

Cerebral venous thrombosis: Diagnosis and management in the emergency department setting.

Am J Emerg Med 2021 Mar 16;47:24-29. Epub 2021 Mar 16.

Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States. Electronic address:

Introduction: Cerebral venous thrombosis (CVT) is an uncommon neurologic emergency associated with significant morbidity and mortality that can be difficult to differentiate from other conditions. It is important for the emergency clinician to be familiar with this disease as it requires a high index of suspicion, and early diagnosis and management can lead to improved outcomes.

Objective: This narrative review provides an evidence-based update concerning the presentation, evaluation, and management of CVT for the emergency clinician.

Discussion: CVT is due to thrombosis of the cerebral veins resulting in obstruction of venous outflow and increased intracranial pressure. Early recognition is important but difficult as the clinical presentation can mimic more common disease patterns. The most common patient population affected includes women under the age of 50. Risk factors for CVT include pregnancy, medications (oral contraceptives), inherited thrombophilia, prior venous thromboembolic event, malignancy, recent infection, and neurosurgery. CVT can present in a variety of ways, but the most common symptom is headache, followed by focal neurologic deficit, seizure, and altered mental status. Imaging studies such as computed tomography (CT) venography or magnetic resonance (MR) venography should be obtained in patients with concern for CVT, as non-contrast CT will be normal or have non-specific findings in most patients. Treatment includes anticoagulation, treating seizures and elevated ICP aggressively, and neurosurgical or interventional radiology consultation in select cases.

Conclusions: CVT can be a challenging diagnosis. Knowledge of the risk factors, patient presentation, evaluation, and management can assist emergency clinicians.
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http://dx.doi.org/10.1016/j.ajem.2021.03.040DOI Listing
March 2021

Hemophagocytic Lymphohistiocytosis in the Emergency Department: Recognizing and Evaluating a Hidden Threat.

J Emerg Med 2021 Mar 18. Epub 2021 Mar 18.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Vermont Medical Center, Burlington, Vermont.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening hematologic disorder resulting from an ineffective and pathologic activation of the immune response system that may mimic common emergency department presentations, including sepsis, acute liver failure, disseminated intravascular coagulation, and flu-like illnesses such as coronavirus disease 2019 (COVID-19).

Objective: This narrative review provides a summary of the disease and recommendations for the recognition and diagnostic evaluation of HLH with a focus on the emergency clinician.

Discussion: Though the condition is rare, mortality rates are high, ranging from 20% to 80% and increasing with delays in treatment. Importantly, HLH has been recognized as a severe variation of the cytokine storm associated with COVID-19. Common features include a history of infection or malignancy, fever, splenomegaly or hepatomegaly, hyperferritinemia, cytopenias, coagulopathies, abnormal liver enzymes, and hypertriglyceridemia. Using specific features of the history, physical examination, laboratory studies, and tools such as the HScore, HLH-2004/2009, and hyperferritinemia thresholds, the emergency clinician can risk-stratify patients and admit for definitive testing. Once diagnosed, disease specific treatment can be initiated.

Conclusion: This review describes the relevant pathophysiology, common presentation findings, and a framework for risk stratification in the emergency department.
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http://dx.doi.org/10.1016/j.jemermed.2021.02.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972988PMC
March 2021

Abdominal Extension of Fournier Gangrene From Undiagnosed Crohn's Disease: A Case Report.

Mil Med 2021 Mar 20. Epub 2021 Mar 20.

Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, TX 78234, USA.

Cellulitis and abscess are common skin infections in military populations. Although complications of necrotizing soft tissue infections (NSTIs) such as Fournier Gangrene (FG) are rare, they are associated with significant morbidity and mortality. Laboratory and radiological studies may aid in the evaluation of NSTI; however, focus should remain on physical examination and prompt surgical consultation, as these infections can spread rapidly with significant increases in mortality with delayed management. We present the case of a 37-year-old male soldier with reported history of two distant left inguinal hernia repairs, complaining of increasing buttock pain despite outpatient antibiotic therapy for perineal cellulitis from his primary clinician. Despite normal vital signs and low risk from established NSTI calculator scores, examination revealed crepitus and severe tenderness extending from the buttock through the perineum and scrotum characteristic of FG. Preoperative computed tomography found additional spread of subcutaneous air from these areas into the lower abdomen, likely facilitated by the previously repaired left inguinal hernia. Surgical management necessitated debridement, multiple washouts, and ileostomy. Follow-up evaluations revealed previously undiagnosed Crohn's disease with fistula-in-ano as the inciting factor.
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http://dx.doi.org/10.1093/milmed/usab110DOI Listing
March 2021

Osgood-Schlatter Disease as a Possible Cause of Tibial Tuberosity Avulsion.

Cureus 2021 Feb 10;13(2):e13256. Epub 2021 Feb 10.

Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA.

Osgood-Schlatter disease (OSD) proposes that bony microtrauma of the patellar tendon insertion on the tibial tuberosity may be due to inappropriate stress with adolescent activity, and is a common pathology among pediatric patients. Lack of activity restrictions may further contribute to significant bony damage due to continued quadriceps contraction, which in some cases results in a tibial tuberosity avulsion fracture. Evaluation in the ED should include distal neurovascular status, as compartment syndrome has also been documented. Radiographs are generally definitive for diagnosis; however, bedside ultrasound and CT may help further define injury severity and delineate conservative rather than operative management. We highlight the case of a 13-year-old male with a recently diagnosed history of OSD who presented to the ED for severe knee pain after landing forcefully onto the ipsilateral foot and was found to have a large avulsion fracture of the tibial tuberosity. We also provide a brief review of the literature.
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http://dx.doi.org/10.7759/cureus.13256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7948309PMC
February 2021

Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study.

Resuscitation 2021 Mar 5. Epub 2021 Mar 5.

Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.

Aim: To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics.

Methods: This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality.

Results: Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status.

Conclusions: Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.
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http://dx.doi.org/10.1016/j.resuscitation.2021.02.039DOI Listing
March 2021

A coronavirus disease-2019 induced pancytopenia: A case report.

Am J Emerg Med 2021 Feb 24. Epub 2021 Feb 24.

Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.

As the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) pandemic progresses, various hematologic complications have emerged, often centered around the hypercoagulable state. However, pancytopenia represents a rare but serious complication from SARS-CoV2 infection. While lymphopenia is a common finding, concomitant acute anemia and thrombocytopenia are not commonly reported. We describe a novel case of SARS-CoV2 pancytopenia in a 40-year-old male without active risk factors for cell line derangements but subsequent critical illness.
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http://dx.doi.org/10.1016/j.ajem.2021.02.043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902224PMC
February 2021

Use of Point-of-Care Ultrasound to Confirm Central Venous Catheter Placement and Evaluate for Postprocedural Complications.

J Emerg Med 2021 Feb 24. Epub 2021 Feb 24.

San Antonio Uniformed Services Health Education Consortium (SAUSHEC), Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.

Background: Central venous catheter (CVC) placement is commonly performed in the emergency department (ED), but traditional confirmation of placement includes chest radiograph.

Objective: This manuscript details the use of point-of-care ultrasound (POCUS) to confirm placement of a CVC and evaluate for postprocedural complications.

Discussion: CVC access in the ED setting is an important procedure. Traditional confirmation includes chest radiograph. POCUS is a rapid, inexpensive, and accurate modality to confirm CVC placement and evaluate for postprocedural complications. POCUS after CVC can evaluate lung sliding for pneumothorax and the internal jugular vein for misdirected CVC. A bubble study with POCUS visualizing agitated saline microbubbles within the right heart can confirm venous placement.

Conclusions: POCUS can rapidly and reliably confirm CVC placement, as well as evaluate for postprocedural complications. Knowledge of this technique can assist emergency clinicians.
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http://dx.doi.org/10.1016/j.jemermed.2021.01.032DOI Listing
February 2021

Peripheral nerve block for hip fracture.

Acad Emerg Med 2021 Feb 26. Epub 2021 Feb 26.

Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.

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http://dx.doi.org/10.1111/acem.14239DOI Listing
February 2021

Antiplatelet Agents for Preventing Early Recurrence of Ischemic Stroke or TIA.

Am Fam Physician 2021 03;103(5):Online

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March 2021

Euglycemic diabetic ketoacidosis: Etiologies, evaluation, and management.

Am J Emerg Med 2021 Feb 16;44:157-160. Epub 2021 Feb 16.

Department of Emergency Medicine, Rush University Medical Center, Chicago, IL 60612, United States of America.

Introduction: Diabetic ketoacidosis is an endocrine emergency. A subset of diabetic patients may present with relative euglycemia with acidosis, known as euglycemic diabetic ketoacidosis (EDKA), which is often misdiagnosed due to a serum glucose <250 mg/dL.

Objective: This narrative review evaluates the pathogenesis, diagnosis, and management of EDKA for emergency clinicians.

Discussion: EDKA is comprised of serum glucose <250 mg/dL with an anion gap metabolic acidosis and ketosis. It most commonly occurs in patients with a history of low glucose states such as starvation, chronic liver disease, pregnancy, infection, and alcohol use. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, which result in increased urinary glucose excretion, are also associated with EDKA. The underlying pathophysiology involves insulin deficiency or resistance with glucagon release, poor glucose availability, ketone body production, and urinary glucose excretion. Patients typically present with nausea, vomiting, malaise, or fatigue. The physician must determine and treat the underlying etiology of EDKA. Laboratory assessment includes venous blood gas for serum pH, bicarbonate, and ketones. Management includes resuscitation with intravenous fluids, insulin, and glucose, with treatment of the underlying etiology.

Conclusions: Clinician knowledge of this condition can improve the evaluation and management of patients with EDKA.
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http://dx.doi.org/10.1016/j.ajem.2021.02.015DOI Listing
February 2021

Is the 4AT Score Accurate in Identifying Delirium in Older Adults?

Ann Emerg Med 2021 Feb 18. Epub 2021 Feb 18.

Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX.

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http://dx.doi.org/10.1016/j.annemergmed.2020.12.022DOI Listing
February 2021

Just the facts: updates in COVID-19 therapeutics.

CJEM 2021 Feb 8. Epub 2021 Feb 8.

Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, 60612, USA.

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http://dx.doi.org/10.1007/s43678-020-00078-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7869758PMC
February 2021

Compression therapy for postthrombotic syndrome.

Acad Emerg Med 2021 Feb 1. Epub 2021 Feb 1.

Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois, USA.

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http://dx.doi.org/10.1111/acem.14223DOI Listing
February 2021

Native Mitral Valve Infective Endocarditis From Flossing: A Case Report and Emergency Department Management.

Cureus 2020 Dec 18;12(12):e12144. Epub 2020 Dec 18.

Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA.

Infective endocarditis (IE) is a rare, elusive disease, carrying a 10%-30% mortality. Requiring a high index of suspicion, IE affects damaged native valves and prosthetic valves. While there are a number of inherent risk factors that predispose patients to IE, dental work in the preceding six weeks is often a culprit of disease, colonizing damaged native mitral valves with  species. Traditionally, flossing has been suggested to be protective against IE. We present a case of  subacute IE on a regurgitant native mitral valve secondary to vigorous flossing.
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http://dx.doi.org/10.7759/cureus.12144DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7813535PMC
December 2020

A primer for managing cardiac transplant patients in the emergency department setting.

Am J Emerg Med 2021 03 1;41:130-138. Epub 2021 Jan 1.

Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.

Background: Cardiac transplant is an effective long-term management option for several severe cardiac diseases. These cardiac transplant patients may present to the emergency department with a range of issues involving the cardiac transplantation, including complications due to their transplant as well as altered presentations of disease resulting from their transplant.

Objective: This narrative review provides a focused guide to the evaluation and management of patients with cardiac transplantation and its complications.

Discussion: Cardiac transplant is an effective therapy for end-stage heart failure. A transplanted heart varies both anatomically and physiologically from a native heart. Several significant complications may occur. Graft failure, rejection, and infection are common causes of morbidity and mortality within the first year of transplant. As these patients are on significant immunosuppressive medication regimens, they are at risk of infection, but inadequate immunosuppression increases the risk of acute rejection. A variety of dysrhythmias such as atrial fibrillation and ventricular dysrhythmias may occur. These patients are also at risk of acute coronary syndrome, cardiac allograft vasculopathy, and medication adverse events. Importantly, patients with acute coronary syndrome can have an altered presentation with the so-called "painless" myocardial infarction. Consultation with the transplant physician is recommended, if available, for these patients to assist in evaluation and management.

Conclusions: An understanding of the presentations and various complications that may affect patients with cardiac transplant will assist emergency clinicians in the care of these patients.
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http://dx.doi.org/10.1016/j.ajem.2020.12.071DOI Listing
March 2021

The diamond of death: Hypocalcemia in trauma and resuscitation.

Am J Emerg Med 2021 03 28;41:104-109. Epub 2020 Dec 28.

Brooke Army Medical Center, 3551 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States of America; Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, United States of America. Electronic address:

Introduction: Early recognition and management of hemorrhage, damage control resuscitation, and blood product administration have optimized management of severe trauma. Recent data suggest hypocalcemia exacerbates the ensuing effects of coagulopathy in trauma.

Objective: This narrative review of available literature describes the physiology and role of calcium in trauma resuscitation. Authors did not perform a systematic review or meta-analysis.

Discussion: Calcium is a divalent cation found in various physiologic forms, specifically the bound, inactive state and the unbound, physiologically active state. While calcium plays several important physiologic roles in multiple organ systems, the negative hemodynamic effects of hypocalcemia are crucial to address in trauma patients. The negative ramifications of hypocalcemia are intrinsically linked to components of the lethal triad of acidosis, coagulopathy, and hypothermia. Hypocalcemia has direct and indirect effects on each portion of the lethal triad, supporting calcium's potential position as a fourth component in this proposed lethal diamond. Trauma patients often present hypocalcemic in the setting of severe hemorrhage secondary to trauma, which can be worsened by necessary transfusion and resuscitation. The critical consequences of hypocalcemia in the trauma patient have been repeatedly demonstrated with the associated morbidity and mortality. It remains poorly defined when to administer calcium, though current data suggest that earlier administration may be advantageous.

Conclusions: Calcium is a key component of trauma resuscitation and the coagulation cascade. Recent data portray the intricate physiologic reverberations of hypocalcemia in the traumatically injured patient; however, future research is needed to further guide the management of these patients.
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http://dx.doi.org/10.1016/j.ajem.2020.12.065DOI Listing
March 2021

Cryptococcal meningitis: a review for emergency clinicians.

Intern Emerg Med 2021 Jan 9. Epub 2021 Jan 9.

Department of Emergency Medicine, Brooke Army Medical Center, 3841 Roger Brooke Dr, Fort Sam Houston, TX, 78234, USA.

Introduction: Cryptococcal Meningitis (CM) remains a high-risk clinical condition, and many patients require emergency department (ED) management for complications and stabilization.

Objective: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of CM.

Discussion: This review evaluates the diagnosis, management, and empiric treatment of suspected CM in the ED. CM can easily evade diagnosis with a subacute presentation, and should be considered in any patient with a headache, neurological deficit, or who is immunocompromised. As a definitive diagnosis of CM will not be made in the ED, management of a patient with suspected CM includes prompt diagnostic testing and initiation of empiric treatment. Multiple types of newer Cryptococcal antigen tests provide high sensitivity and specificity both in serum and cerebrospinal fluid (CSF). Patients should be treated empirically for bacterial, fungal, and viral meningitis, specifically with amphotericin B and flucytosine for presumed CM. Additionally, appropriate resuscitation and supportive care, including advanced airway management, management of increased intracranial pressure (ICP), antipyretics, intravenous fluids, and isolation, should be initiated. Antiretroviral therapy (ART) should not be initiated in the ED for those found or known to be HIV-positive for risk of immune reconstitution inflammatory syndrome (IRIS).

Conclusions: CM remains a rare clinical presentation, but carries significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with an infectious disease specialist is imperative, as is initiating symptomatic care.
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http://dx.doi.org/10.1007/s11739-020-02619-2DOI Listing
January 2021

Electrocardiographic manifestations of COVID-19.

Am J Emerg Med 2021 Mar 29;41:96-103. Epub 2020 Dec 29.

Ultrasound Director, Assistant Professor, Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.

Introduction: Coronavirus disease of 2019 (COVID-19) is a lower respiratory tract infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This disease can impact the cardiovascular system and lead to abnormal electrocardiographic (ECG) findings. Emergency clinicians must be aware of the ECG manifestations of COVID-19.

Objective: This narrative review outlines the pathophysiology and electrocardiographic findings associated with COVID-19.

Discussion: COVID-19 is a potentially critical illness associated with a variety of ECG abnormalities, with up to 90% of critically ill patients demonstrating at least one abnormality. The ECG abnormalities in COVID-19 may be due to cytokine storm, hypoxic injury, electrolyte abnormalities, plaque rupture, coronary spasm, microthrombi, or direct endothelial or myocardial injury. While sinus tachycardia is the most common abnormality, others include supraventricular tachycardias such as atrial fibrillation or flutter, ventricular arrhythmias such as ventricular tachycardia or fibrillation, various bradycardias, interval and axis changes, and ST segment and T wave changes. Several ECG presentations are associated with poor outcome, including atrial fibrillation, QT interval prolongation, ST segment and T wave changes, and ventricular tachycardia/fibrillation.

Conclusions: This review summarizes the relevant ECG findings associated with COVID-19. Knowledge of these findings in COVID-19-related electrocardiographic presentations may assist emergency clinicians in the evaluation and management of potentially infected and infected patients.
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http://dx.doi.org/10.1016/j.ajem.2020.12.060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771377PMC
March 2021

Diagnosis and management of Ludwig's angina: An evidence-based review.

Am J Emerg Med 2021 03 23;41:1-5. Epub 2020 Dec 23.

Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America. Electronic address:

Background: Ludwig's angina is a potentially deadly condition that must not be missed in the emergency department (ED).

Objective: The purpose of this narrative review article is to provide a summary of the epidemiology, pathophysiology, diagnosis, and management of Ludwig's angina with a focus on emergency clinicians.

Discussion: Ludwig's angina is a rapidly spreading infection that involves the floor of the mouth. It occurs more commonly in those with poor dentition or immunosuppression. Patients may have a woody or indurated floor of the mouth with submandibular swelling. Trismus is a late finding. Computed tomography of the neck soft tissue with contrast is preferred if the patient is able to safely leave the ED and can tolerate lying supine. Point-of-care ultrasound can be a useful adjunct, particularly in those who cannot tolerate lying supine. Due to the threat of rapid airway compromise, emergent consultation to anesthesia and otolaryngology, if available, may be helpful if a definitive airway is required. The first line approach for airway intervention in the ED is flexible intubating endoscopy with preparation for a surgical airway. Broad spectrum antibiotics and surgical source control are keys in treating the infection. These patients should then be admitted to the intensive care unit for close airway observation.

Conclusion: Ludwig's angina is a life-threatening condition that all emergency clinicians need to consider. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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http://dx.doi.org/10.1016/j.ajem.2020.12.030DOI Listing
March 2021

Do Systemic Corticosteroids Reduce Mortality in Critically Ill Adult Patients With COVID-19?

Ann Emerg Med 2021 04 10;77(4):407-409. Epub 2020 Oct 10.

Department of Emergency Medicine, Rush University Medical Center, Chicago, IL.

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http://dx.doi.org/10.1016/j.annemergmed.2020.10.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7547602PMC
April 2021

Diagnostic accuracy of the history, physical examination, and laboratory testing for giant cell arteritis.

Acad Emerg Med 2020 Dec 20. Epub 2020 Dec 20.

Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.

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http://dx.doi.org/10.1111/acem.14196DOI Listing
December 2020

Low-dose chest CT had 95% sensitivity and 91% specificity for diagnosing COVID-19 in patients with clinical symptoms.

Authors:
Brit Long

Ann Intern Med 2020 12;173(12):JC68

San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas, USA (B.L.).

Source Citation: Schulze-Hagen M, Hübel C, Meier-Schroers M, et al. Dtsch Arztebl Int. 2020;117:389-95. 32762834.
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http://dx.doi.org/10.7326/ACPJ202012150-068DOI Listing
December 2020

Interrater Agreement and Reliability of Burn Size Estimations between Emergency Physicians and Burn Unit.

J Burn Care Res 2020 Dec 11. Epub 2020 Dec 11.

Department of Emergency Medicine, Brooke Army Medical Center, Roger Brooke Dr, Fort Sam Houston, Texas.

Objective: The initial approach to burn injuries has remained essentially unchanged over the past several decades and revolves around trauma assessment and fluid resuscitation, frequently occurring in the emergency department (ED). While previous research suggests that emergency physicians (EP) are poor estimators at total body surface area (TBSA) affected, we believe that estimation differences are improving drastically. This study investigated the interrater agreement and reliability of burn size estimations at an academic ED and its cohabiting burn unit.

Methods: This single center, retrospective study was conducted at a trauma center with a cohabited burn unit. The study included adult patients admitted to the burn unit after receiving paired burn size estimations from EPs and the burn unit. The primary endpoint was the interrater agreement, measured by kappa (k), of 10% TBSA estimation intervals. The secondary endpoint was the intraclass correlation coefficient (ICC), evaluating the reliability of absolute TBSA estimations.

Results: A chart review was performed for patients evaluated from November 1, 2016 to July 31, 2019. 1,184 patients were admitted to the burn unit, 1,176 of which met inclusion criteria for the primary endpoint. The interrater agreement of TBSA between EPs and the burn unit was 0.586, while the weighted k was 0.775. These values correlate to moderate and substantial agreements, respectively. Additionally, 971 patients had specific TBSA estimations from paired EPs and the burn unit which were used for the secondary endpoint. The ICC between EPs and the burn unit was 0.966, demonstrating an excellent agreement. Further sub-analysis was performed, revealing absolute mean overestimation and underestimation differences of 3.93% and 2.93%, respectively.

Conclusion: EPs at academic institutions with cohabited burn units are accurate estimators of TBSA in the assessment of burn injuries.
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http://dx.doi.org/10.1093/jbcr/iraa212DOI Listing
December 2020

An Analysis of Conflicts Across Role 1 Guidelines.

Mil Med 2020 Nov 24. Epub 2020 Nov 24.

US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX 78234-7767, USA.

Introduction: Role 1 care is vital to patient survival and includes many echelons of care from point-of-injury first aid to medical attention at battalion aid stations. Many guidelines are written for Role 1 care providers to optimize care for different scenarios. Differences in the guidelines lead to confusion and discrepancies between the types of treatment medical care providers provide. Although the guidelines were written for different areas of care, uniformity between the guidelines is needed and will lead to a reduced mortality rate.

Materials And Methods: It was determined that the Tactical Combat Casualty Care Guidelines, Prolonged Field Care Guidelines, Joint Trauma System Clinical Practice Guidelines, and Standard Medical Operating Guidelines from medical evacuation were the military medical guidelines most relevant to Role 1 care. These Guidelines were compared side by side to determine the differences between them.

Results: Although the guidelines were largely similar, many major differences were found between them. Our online tables contain large inconsistences between guidelines including direct contradictions in conversion of junctional tourniquets and the administration of tranexamic acid.

Conclusions: Role 1 care is vital to patient survival, including care from point of injury to battalion aid stations, but the guidelines available to instruct this care and the guidance on which personnel should provide this care are conflicting. This lack of clarity and consistency may adversely impact treatment outcomes. The reduction or elimination of conflicting information across the various guidelines, augmentation of guidance for pediatric care, more specific guidance for unique levels of care, and clearer delineation of the Role 1 phases of care (as well as which guidelines are most appropriate to each) should be considered as urgent priorities within the military medical community.
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http://dx.doi.org/10.1093/milmed/usaa460DOI Listing
November 2020

Select Burn Blisters Should not be Left Intact.

Ann Emerg Med 2020 12;76(6):771-773

Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, San Antonio, TX.

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http://dx.doi.org/10.1016/j.annemergmed.2020.04.017DOI Listing
December 2020