Introduction: Early Emergency Department (ED) identification of septic patients at risk of subsequent deterioration is necessary in order to optimize disposition. High-risk patients admitted directly from the ED to the ICU have better outcomes than those admitted to the floor first. Initial ED serum lactate level has been associated with 28-day mortality in admitted patients, but there is little evidence on its use in predicting short-term deterioration. Furthermore, it is unclear whether the addition of respiratory rate (RR) to lactate would create a stronger predictive model of deterioration than either alone. Methods: Prospective cohort study of ED patients (age ≥18) screened and treated for sepsis (defined as physician suspicion of infection and 2 or more of the SIRS criteria). Lactate and vital signs were obtained within 2 hours of ED arrival. Main outcome was deterioration (defined as any of the following: death; ICU admission >24 hours; Intubation; Vasoactive medications for >1 hour; or Non-invasive positive pressure ventilation for >1 hour) within 72 hours. Patients meeting an endpoint within 1 hour of arrival were excluded. Discharged patients were contacted at 72 hours to ensure that they had not met the endpoint or presented to another institution. Results: 985 patients presenting to either of two urban high-volume EDs were enrolled, of whom 84 (8.5%) met the primary outcome. Initial serum lactate ≥ 4.0 had a specificity of 97.4% (95% CI, 94.1-100%), but a sensitivity of 27.4% (95% CI, 17-8-36.9%) for predicting deterioration. Of patients with a lactate ≥ 4.0, 4 (8.7%) were discharged home, and did not reach an endpoint at 72 hours. Lactate <2.0 had a sensitivity of 95.5% (95% CI: 93.4-97.1%) and specificity of 84.5% (95% CI: 80.4-88.6%) for ruling out 72-hour deterioration. Of patients with a lactate <2.0, 224 (56.1%) were discharged home. Combining lactate with RR (AUC: 0.72, 95% CI: 0.66-0.79) did not yield better predictive capability than lactate alone (AUC: 0.70, 95% CI: 0.64-0.76). Conclusion: Initial ED lactate is predictive of deterioration within 72 hours in patients with sepsis. The combination of lactate and RR was not more predictive of deterioration than lactate alone. This suggests that serum lactate has a role in predicting deterioration in patients with sepsis, and has utility in determining disposition.

Atrial fibrillation (AF) is a frequent reason for emergency department visits. According to current guidelines either rate- or rhythm-control are acceptable therapeutic options in such situations. In this report, we present the complicated clinical course of a patient with AF and a rapid ventricular response. Because of paroxysmal AF, the patient was on chronic oral anticoagulation therapy with warfarin. Pharmacological treatment was ineffective to control ventricular rate, and immediate synchronized electrical cardioversion was performed. One hour later, the patient complained of chest pain in combination with marked ST-segment elevation in the anterior leads. Cardiac catheterization with optical coherence tomography disclosed plaque rupture in the left main coronary artery without other significant stenosis. Stent implantation was performed successfully. During the course of the hospital stay, the patient remained asymptomatic and the ST-segment elevations resolved. However, despite treatment with amiodarone it was not possible to keep the patient permanently in sinus rhythm. Therefore, a biventricular pacemaker was implanted and AV node ablation performed.

Introduction: A recent cross-sectional study reported a 17.3% prevalence of pulmonary embolism (PE) among patients with syncope. However, the study had several flaws including spectrum and work-up bias with over-diagnosis due to excessive investigations. We sought to evaluate the prevalence of PE among Canadian emergency department (ED) patients presenting with syncope. Methods: We enrolled adults with syncope at 5 EDs and collected demographics, proportion of patients evaluated for suspected PE, their Wells PE score values and results of investigations [d-dimer, computed angiography (CT) of chest or ventilation-perfusion (VQ) scan]. 30-day adjudicated outcome included diagnosis of PE requiring treatment. We used descriptive statistics to report the results. Results: 4,739 patients [mean age 54.3 years, 54.4% females, and 587 (12.4%) hospitalized] were enrolled. 323 patients (6.8%) had further evaluation and investigations performed for suspected PE: 255 patients had D-dimer performed, 140 had CT chest and 17 had VQ performed. Of the 323 patients, 300 patients were low risk (Wells score ≤4) and 23 were high-risk (score >4). A total of 16 patients (0.3%) in the study cohort were diagnosed with PE: 10 patients were diagnosed in the ED, 5 patients were diagnosed while hospitalized as inpatient, and 1 patient was diagnosed on a return ED visit. Overall the prevalence of PE was 0.3% among all ED patients with syncope; and a 0.9% among those hospitalized for syncope. Conclusion: Our study shows that the prevalence of PE is very low among all patients presenting to the ED with syncope. The prevalence is also very low among those hospitalized for syncope than previously reported. While PE should be suspected and further investigations performed among syncope patients if clinically appropriate, caution should also be taken against indiscriminate over-investigations for PE.

Penetrating penile injuries occur mostly in industrial/work accidents, automobile accidents, or as a result of sexual curiosity and attempts at self-expression/mutilation. In this case report, the authors describe an accidental nailgun injury to the penis of a 46-year-old man. We discuss the management of such injuries in the emergency department, including the utility of a dorsal penile block for regional anesthesia. Although exceptionally rare, familiarity with penetrating lower urinary tract injuries may reduce their long-term repercussions on genitourinary and sexual health.

Point of care ultrasound in the emergency department (ED) is increasingly being used to diagnose time-sensitive, vision-threatening conditions. We present a case of a 64-year-old female who presented to the ED with a three-day history of worsening left eye floaters. Point of care ocular ultrasound demonstrated a posterior chamber containing many echogenic opacities of varying size without acoustic shadowing. Movement of the eye resulted in significant after-movement of these opacities, giving the classic “washing machine” appearance seen with vitreous hemorrhage (VH). Based on these ultrasound findings, the patient was diagnosed with a VH and was referred to ophthalmology. The consulting ophthalmologist ultimately diagnosed the patient with asteroid hyalosis without VH. Asteroid hyalosis is a benign condition of the vitreous resulting in calcium phosphate and lipid deposits that can mimic more serious VH on point of care ultrasound. Knowledge of this mimic is helpful for communication with specialists and for awareness of the potential for misdiagnosis with ocular ultrasound.

The predominant causes of acute mechanical small bowel obstruction in geriatric patients are adhesions and hernias, which is not much different than in other adult age groups. Unusual etiologies may be encountered, such as volvulus or gallstone ileus, but a displaced feeding gastrostomy tube is a distinctly rare cause of intestinal obstruction which needs to be considered by emergency physicians as it may be increasingly encountered.