Case

A 34-year-old man presented to our ED via emergency medical services (EMS) following a syncopal episode. The patient stated that as he was getting ready for work earlier that morning, he experienced sudden lightheadedness and passed out, whereupon his wife immediately called EMS. The patient denied any previous history of syncope, but said he had been experiencing frequent episodes of nausea and vomiting over the past week. He also complained of a mild occipital headache that acetaminophen had failed to relieve.

The patient had been seen at a different ED 3 days earlier for nausea and vomiting. After evaluating the patient, the emergency physician (EP) at this facility felt the most likely cause of the patient’s gastrointestinal issues was related to hydralazine, his antihypertensive medication, and advised the patient to discontinue its use.

During evaluation at our ED, the patient denied fever, chills, neck stiffness, numbness, weakness, tingling of the extremities, or difficulty walking. He also denied chest pain, shortness of breath, or urinary symptoms. The patient’s medical history was significant only for hypertension; he had not taken any antihypertensive or other medications for the past 3 days, as previously instructed by the EP at the other ED. The patient denied alcohol or drug abuse.

On physical examination, the patient’s vital signs were: temperature, 98.6°F; heart rate, 58 beats/minute; blood pressure, 130/90 mm Hg; and respiratory rate, 16 breaths/minute. Oxygen saturation was 100% on room air. Examination of the head was normal and without evidence of trauma. Both pupils measured 4 mm and were equally round and reactive to light; the patient’s extraocular movements were intact. The remainder of the head, eyes, ears, nose, and throat examination was normal. The neck was supple, without masses or meningeal signs. The cardiopulmonary and abdominal examinations were all normal. On neurological examination, the patient was awake, alert, and oriented to person, place, and time. Cranial nerves II through XII were intact, and the patient had 5/5 motor strength in all four extremities and a normal gait.

Because we were concerned about the patient’s unexplained syncopal episode, we ordered laboratory tests, including a complete blood count (CBC), evaluation of electrolytes and glucose levels, and kidney function. In addition, we also ordered an electrocardiogram (ECG) and a noncontrast computed tomography (CT) scan of the head. All laboratory test results were within normal range. The ECG, however, demonstrated sinus bradycardia (approximately 58 beats/minute), a normal PR and QRS interval, a normal axis, and an incomplete right bundle branch block with tall, large, splayed upright T waves in the precordial leads (Figure). Based on the abnormal ECG results, we ordered serum cardiac marker studies, the values of which were all within normal range. The noncontrast CT scan of the head revealed a low-density posterior fossa mass compressing the fourth ventricle with secondary hydrocephalus.

The patient was placed with his head in an upright position and given 1 g/kg mannitol and 10 mg dexamethasone intravenously (IV). Neurosurgery services were consulted, and the patient underwent surgery the following morning. Surgery confirmed the presence of a hemangioblastoma. The hemangioblastoma was successfully excised, and the patient had an uneventful recovery. Interestingly, the significant T-wave changes in the precordial leads were no longer present postoperatively.

Discussion

Syncope and near-syncope are common reasons for ED visits. Syncope is a syndrome characterized by a transient, self-limited episode of loss of consciousness occurring as a result of a brief interruption of the oxygen supply to the brain.¹ This interruption is almost always due to a transient cessation of blood flow.¹ In true syncope (as opposed to seizures or hypoglycemia), the episode is characterized by a rapid onset of loss of consciousness—with or without warning symptoms.¹ It is important to determine the cause of syncope, because 7% to 23% of such patients will suffer serious outcomes within 7 to 30 days of their ED visit—either within a hospital setting or at home.²

Etiology

There are many causes of syncope. In most cases, the etiology falls under one of three broad categories: neurally mediated (or reflex mediated), orthostatic hypotensive-mediated, or cardiovascular (CV)-mediated. Less common causes of syncope include cerebrovascular injury.¹ The Table outlines both common and uncommon causes of syncope.

On presentation, our patient had several possible causes for his syncopal episode: an abnormal ECG (CV); multiple episodes of emesis (volume depletion); and headache (cerebrovascular). The EP worked up all three of these signs and symptoms simultaneously as is the appropriate protocol when evaluating an ED patient presenting with undifferentiated syncope.

Signs and Symptoms

Patients with undiagnosed brain tumors normally present with headache, seizures, nausea, vomiting, focal neurological deficits, or an altered mental status.³ Syncope is a very rare manifestation of a brain tumor³; however, our patient did complain of headache, nausea, and vomiting.

In addition to the unusual cause of the syncope, the abnormally large upright T waves make this case even more notable. T-wave changes are the most common ECG abnormality, seen in about 50% of abnormal tracings reviewed in a hospital population and in 2.4% of all ECGs.⁴

In general, T-wave changes are a result of local changes in the duration of repolarization. T-wave inversion is the most common T-wave abnormality and is typically observed in the setting of ischemia, post-ingestion of food, following an episode of tachycardia or anxiety, and autonomic dysfunction.⁵ However, in patients who have a cerebral etiology (usually hemorrhage), the T-wave changes may be either upright (as in our case) or inverted.⁵ Historically, subarachnoid hemorrhage (SAH) has been associated with ST-segment elevation and T-wave inversion. Hypothalamic stimulation and autonomic dysfunction have been linked to abnormal T-waves, but this has not been conclusively proven to be the cause of the abnormality.⁶ For all of the aforementioned reasons, the specificity for a given cause of T-wave changes is exceedingly low.⁵

Hyperacute T-wave amplitude, with prominent symmetrical T waves in at least two continuous leads, may be the earliest sign of acute transmural myocardial infarction (MI).⁷ It usually persists for only a brief time before other ECG findings of acute MI are observed. Other common causes of hyperacute T waves include hyperkalemia (usually narrow-based, and peaked), early repolarization, left ventricular hypertrophy, and acute myocarditis.⁸ Less common causes of prominent T waves include pre-excitation  syndromes, pericarditis, and scorpion stings.^9,10

Summary

It is unclear why our patient, who had a hemangioblastoma, demonstrated hyperacute T-wave abnormality on ECG. The abnormal upright T waves may have occurred secondary to the same theories regarding SAH, hypothalamic stimulation, or autonomic dysfunction. Regardless of the underlying etiology, this case serves as a reminder to the EP that not all T-wave changes on ECG are cardiac in origin. 

Case

A 34-year-old man presented to our ED via emergency medical services (EMS) following a syncopal episode. The patient stated that as he was getting ready for work earlier that morning, he experienced sudden lightheadedness and passed out, whereupon his wife immediately called EMS. The patient denied any previous history of syncope, but said he had been experiencing frequent episodes of nausea and vomiting over the past week. He also complained of a mild occipital headache that acetaminophen had failed to relieve.

The patient had been seen at a different ED 3 days earlier for nausea and vomiting. After evaluating the patient, the emergency physician (EP) at this facility felt the most likely cause of the patient’s gastrointestinal issues was related to hydralazine, his antihypertensive medication, and advised the patient to discontinue its use.

During evaluation at our ED, the patient denied fever, chills, neck stiffness, numbness, weakness, tingling of the extremities, or difficulty walking. He also denied chest pain, shortness of breath, or urinary symptoms. The patient’s medical history was significant only for hypertension; he had not taken any antihypertensive or other medications for the past 3 days, as previously instructed by the EP at the other ED. The patient denied alcohol or drug abuse.

On physical examination, the patient’s vital signs were: temperature, 98.6°F; heart rate, 58 beats/minute; blood pressure, 130/90 mm Hg; and respiratory rate, 16 breaths/minute. Oxygen saturation was 100% on room air. Examination of the head was normal and without evidence of trauma. Both pupils measured 4 mm and were equally round and reactive to light; the patient’s extraocular movements were intact. The remainder of the head, eyes, ears, nose, and throat examination was normal. The neck was supple, without masses or meningeal signs. The cardiopulmonary and abdominal examinations were all normal. On neurological examination, the patient was awake, alert, and oriented to person, place, and time. Cranial nerves II through XII were intact, and the patient had 5/5 motor strength in all four extremities and a normal gait.

Because we were concerned about the patient’s unexplained syncopal episode, we ordered laboratory tests, including a complete blood count (CBC), evaluation of electrolytes and glucose levels, and kidney function. In addition, we also ordered an electrocardiogram (ECG) and a noncontrast computed tomography (CT) scan of the head. All laboratory test results were within normal range. The ECG, however, demonstrated sinus bradycardia (approximately 58 beats/minute), a normal PR and QRS interval, a normal axis, and an incomplete right bundle branch block with tall, large, splayed upright T waves in the precordial leads (Figure). Based on the abnormal ECG results, we ordered serum cardiac marker studies, the values of which were all within normal range. The noncontrast CT scan of the head revealed a low-density posterior fossa mass compressing the fourth ventricle with secondary hydrocephalus.

The patient was placed with his head in an upright position and given 1 g/kg mannitol and 10 mg dexamethasone intravenously (IV). Neurosurgery services were consulted, and the patient underwent surgery the following morning. Surgery confirmed the presence of a hemangioblastoma. The hemangioblastoma was successfully excised, and the patient had an uneventful recovery. Interestingly, the significant T-wave changes in the precordial leads were no longer present postoperatively.

Discussion

Syncope and near-syncope are common reasons for ED visits. Syncope is a syndrome characterized by a transient, self-limited episode of loss of consciousness occurring as a result of a brief interruption of the oxygen supply to the brain.¹ This interruption is almost always due to a transient cessation of blood flow.¹ In true syncope (as opposed to seizures or hypoglycemia), the episode is characterized by a rapid onset of loss of consciousness—with or without warning symptoms.¹ It is important to determine the cause of syncope, because 7% to 23% of such patients will suffer serious outcomes within 7 to 30 days of their ED visit—either within a hospital setting or at home.²

Etiology

There are many causes of syncope. In most cases, the etiology falls under one of three broad categories: neurally mediated (or reflex mediated), orthostatic hypotensive-mediated, or cardiovascular (CV)-mediated. Less common causes of syncope include cerebrovascular injury.¹ The Table outlines both common and uncommon causes of syncope.

On presentation, our patient had several possible causes for his syncopal episode: an abnormal ECG (CV); multiple episodes of emesis (volume depletion); and headache (cerebrovascular). The EP worked up all three of these signs and symptoms simultaneously as is the appropriate protocol when evaluating an ED patient presenting with undifferentiated syncope.

Signs and Symptoms

Patients with undiagnosed brain tumors normally present with headache, seizures, nausea, vomiting, focal neurological deficits, or an altered mental status.³ Syncope is a very rare manifestation of a brain tumor³; however, our patient did complain of headache, nausea, and vomiting.

In addition to the unusual cause of the syncope, the abnormally large upright T waves make this case even more notable. T-wave changes are the most common ECG abnormality, seen in about 50% of abnormal tracings reviewed in a hospital population and in 2.4% of all ECGs.⁴

In general, T-wave changes are a result of local changes in the duration of repolarization. T-wave inversion is the most common T-wave abnormality and is typically observed in the setting of ischemia, post-ingestion of food, following an episode of tachycardia or anxiety, and autonomic dysfunction.⁵ However, in patients who have a cerebral etiology (usually hemorrhage), the T-wave changes may be either upright (as in our case) or inverted.⁵ Historically, subarachnoid hemorrhage (SAH) has been associated with ST-segment elevation and T-wave inversion. Hypothalamic stimulation and autonomic dysfunction have been linked to abnormal T-waves, but this has not been conclusively proven to be the cause of the abnormality.⁶ For all of the aforementioned reasons, the specificity for a given cause of T-wave changes is exceedingly low.⁵

Hyperacute T-wave amplitude, with prominent symmetrical T waves in at least two continuous leads, may be the earliest sign of acute transmural myocardial infarction (MI).⁷ It usually persists for only a brief time before other ECG findings of acute MI are observed. Other common causes of hyperacute T waves include hyperkalemia (usually narrow-based, and peaked), early repolarization, left ventricular hypertrophy, and acute myocarditis.⁸ Less common causes of prominent T waves include pre-excitation  syndromes, pericarditis, and scorpion stings.^9,10

Summary

It is unclear why our patient, who had a hemangioblastoma, demonstrated hyperacute T-wave abnormality on ECG. The abnormal upright T waves may have occurred secondary to the same theories regarding SAH, hypothalamic stimulation, or autonomic dysfunction. Regardless of the underlying etiology, this case serves as a reminder to the EP that not all T-wave changes on ECG are cardiac in origin. 

Case

A 34-year-old man presented to our ED via emergency medical services (EMS) following a syncopal episode. The patient stated that as he was getting ready for work earlier that morning, he experienced sudden lightheadedness and passed out, whereupon his wife immediately called EMS. The patient denied any previous history of syncope, but said he had been experiencing frequent episodes of nausea and vomiting over the past week. He also complained of a mild occipital headache that acetaminophen had failed to relieve.

The patient had been seen at a different ED 3 days earlier for nausea and vomiting. After evaluating the patient, the emergency physician (EP) at this facility felt the most likely cause of the patient’s gastrointestinal issues was related to hydralazine, his antihypertensive medication, and advised the patient to discontinue its use.

During evaluation at our ED, the patient denied fever, chills, neck stiffness, numbness, weakness, tingling of the extremities, or difficulty walking. He also denied chest pain, shortness of breath, or urinary symptoms. The patient’s medical history was significant only for hypertension; he had not taken any antihypertensive or other medications for the past 3 days, as previously instructed by the EP at the other ED. The patient denied alcohol or drug abuse.

On physical examination, the patient’s vital signs were: temperature, 98.6°F; heart rate, 58 beats/minute; blood pressure, 130/90 mm Hg; and respiratory rate, 16 breaths/minute. Oxygen saturation was 100% on room air. Examination of the head was normal and without evidence of trauma. Both pupils measured 4 mm and were equally round and reactive to light; the patient’s extraocular movements were intact. The remainder of the head, eyes, ears, nose, and throat examination was normal. The neck was supple, without masses or meningeal signs. The cardiopulmonary and abdominal examinations were all normal. On neurological examination, the patient was awake, alert, and oriented to person, place, and time. Cranial nerves II through XII were intact, and the patient had 5/5 motor strength in all four extremities and a normal gait.

Because we were concerned about the patient’s unexplained syncopal episode, we ordered laboratory tests, including a complete blood count (CBC), evaluation of electrolytes and glucose levels, and kidney function. In addition, we also ordered an electrocardiogram (ECG) and a noncontrast computed tomography (CT) scan of the head. All laboratory test results were within normal range. The ECG, however, demonstrated sinus bradycardia (approximately 58 beats/minute), a normal PR and QRS interval, a normal axis, and an incomplete right bundle branch block with tall, large, splayed upright T waves in the precordial leads (Figure). Based on the abnormal ECG results, we ordered serum cardiac marker studies, the values of which were all within normal range. The noncontrast CT scan of the head revealed a low-density posterior fossa mass compressing the fourth ventricle with secondary hydrocephalus.

The patient was placed with his head in an upright position and given 1 g/kg mannitol and 10 mg dexamethasone intravenously (IV). Neurosurgery services were consulted, and the patient underwent surgery the following morning. Surgery confirmed the presence of a hemangioblastoma. The hemangioblastoma was successfully excised, and the patient had an uneventful recovery. Interestingly, the significant T-wave changes in the precordial leads were no longer present postoperatively.

Discussion

Syncope and near-syncope are common reasons for ED visits. Syncope is a syndrome characterized by a transient, self-limited episode of loss of consciousness occurring as a result of a brief interruption of the oxygen supply to the brain.¹ This interruption is almost always due to a transient cessation of blood flow.¹ In true syncope (as opposed to seizures or hypoglycemia), the episode is characterized by a rapid onset of loss of consciousness—with or without warning symptoms.¹ It is important to determine the cause of syncope, because 7% to 23% of such patients will suffer serious outcomes within 7 to 30 days of their ED visit—either within a hospital setting or at home.²

Etiology

There are many causes of syncope. In most cases, the etiology falls under one of three broad categories: neurally mediated (or reflex mediated), orthostatic hypotensive-mediated, or cardiovascular (CV)-mediated. Less common causes of syncope include cerebrovascular injury.¹ The Table outlines both common and uncommon causes of syncope.

On presentation, our patient had several possible causes for his syncopal episode: an abnormal ECG (CV); multiple episodes of emesis (volume depletion); and headache (cerebrovascular). The EP worked up all three of these signs and symptoms simultaneously as is the appropriate protocol when evaluating an ED patient presenting with undifferentiated syncope.

Signs and Symptoms

Patients with undiagnosed brain tumors normally present with headache, seizures, nausea, vomiting, focal neurological deficits, or an altered mental status.³ Syncope is a very rare manifestation of a brain tumor³; however, our patient did complain of headache, nausea, and vomiting.

In addition to the unusual cause of the syncope, the abnormally large upright T waves make this case even more notable. T-wave changes are the most common ECG abnormality, seen in about 50% of abnormal tracings reviewed in a hospital population and in 2.4% of all ECGs.⁴

In general, T-wave changes are a result of local changes in the duration of repolarization. T-wave inversion is the most common T-wave abnormality and is typically observed in the setting of ischemia, post-ingestion of food, following an episode of tachycardia or anxiety, and autonomic dysfunction.⁵ However, in patients who have a cerebral etiology (usually hemorrhage), the T-wave changes may be either upright (as in our case) or inverted.⁵ Historically, subarachnoid hemorrhage (SAH) has been associated with ST-segment elevation and T-wave inversion. Hypothalamic stimulation and autonomic dysfunction have been linked to abnormal T-waves, but this has not been conclusively proven to be the cause of the abnormality.⁶ For all of the aforementioned reasons, the specificity for a given cause of T-wave changes is exceedingly low.⁵

Hyperacute T-wave amplitude, with prominent symmetrical T waves in at least two continuous leads, may be the earliest sign of acute transmural myocardial infarction (MI).⁷ It usually persists for only a brief time before other ECG findings of acute MI are observed. Other common causes of hyperacute T waves include hyperkalemia (usually narrow-based, and peaked), early repolarization, left ventricular hypertrophy, and acute myocarditis.⁸ Less common causes of prominent T waves include pre-excitation  syndromes, pericarditis, and scorpion stings.^9,10

Summary

It is unclear why our patient, who had a hemangioblastoma, demonstrated hyperacute T-wave abnormality on ECG. The abnormal upright T waves may have occurred secondary to the same theories regarding SAH, hypothalamic stimulation, or autonomic dysfunction. Regardless of the underlying etiology, this case serves as a reminder to the EP that not all T-wave changes on ECG are cardiac in origin. 

Traumatic eye injuries ranging from mild corneal abrasions to penetrating globe injuries are commonly seen in the ED, and ocular trauma accounts for nearly 1% of all complaints in the ED.¹ Up to 29% of facial fractures have associated eye injuries.² Emergency physicians (EPs) must be aware of possible eye injuries, including traumatic vision loss, and the indicators for emergent interventions.

Tension pneumo-orbitum following facial trauma is rarely reported. We present a case of orbital compartment syndrome (OCS) in an elderly woman who sustained an orbital floor fracture and required emergent lateral canthotomy to preserve vision.

Case

A 76-year-old woman presented to the ED for evaluation of pain, swelling, and loss of vision in the right eye. She said she had been sitting in a chair tying her shoes when she lost her balance and fell forward, striking her head and the right side of her face against the floor. She experienced no loss of consciousness and denied any neck pain, jaw pain, or dizziness. She also denied any chest pain, shortness of breath, weakness, or loss of function in either her arms or legs. She did, however, note a small nosebleed that had stopped before she arrived at the ED. The patient’s primary complaint was a possible nasal bone fracture.

Her medical history was significant for hypertension and coronary artery disease. Her medications include amitriptyline, an antihistamine, aspirin, clopidogrel, diltiazem, folic acid, furosemide, hydralazine, levothyroxine, prednisone, and zolpidem. She stated that she was allergic to amoxicillin and sulfa drugs.

The patient’s vital signs at presentation were: blood pressure (BP), 193/82 mm Hg; heart rate, 71 beats/minute; respiratory rate, 16 breaths/minute; and temperature, 97°F. She was alert, oriented, and in no distress. Her head and neck examination showed no scalp lacerations or swelling. There was, however, significant swelling and ecchymosis around the right eye and swelling and ecchymosis around the nose, with dried blood in both nares. No septal hematoma was present. The patient had tenderness to palpation over the infraorbital area and nose. No gross facial instability was present, and Battle sign was not appreciated. No jaw or dental abnormalities were noted.

The patient’s right pupil was fixed and dilated, and she could not perceive light. She did have upward and lateral movement of the eye, but was unable to look down. A minimal amount of proptosis was noted. Her intraocular pressure (IOP) was elevated at 54 mm Hg (normal range, 10-20 mm Hg). The remainder of the examination, including the neurological examination, was unremarkable.

The patient received emergent head and facial computed tomography (CT) scans. The head CT showed no acute intracranial hemorrhage, mass, or infarct. The facial CT was read as a right orbital floor fracture with intraorbital air, and a right maxillary sinus hematoma. Laboratory evaluation revealed a hematocrit of 38% and a platelet count of 544,000/mcL (normal range, 150,000-450,000/mcL). The prothrombin time was 10.9 seconds (normal range, 11-13.5 seconds); the international normalized ratio was 0.8 (normal range, 0.8-1.1); and the partial thromboplastin time was 22.5 seconds (normal range, 25-35 seconds).

Because the patient was at risk for permanent visual impairment due to increased IOP from the injury, a lateral canthotomy was immediately performed. A small amount of air was released, and the proptosis was notably reduced.

At this point, the ophthalmologist arrived and used an 18-gauge needle to explore the retrobulbar space. Two pockets of air were released, which markedly reduced the tactile pressure of the globe. Repeat tonography of the globe was 28 mm Hg. The wound was left open to drain, and the patient was started on azithromycin. She was discharged home to follow up with ophthalmology.

The patient presented to the ED 2 months later for an unrelated condition. At that time, she reported a complete return of her vision with no deficits and no noticeable scarring around the eye.

Discussion

The orbit is an enclosed space, bordered by bone laterally and posteriorly—the orbital septa superiorly and inferiorly, and the globe anteriorly.³ The lateral canthus is a combined tendon-ligament that helps attach the tarsal plates of the lids and the orbicularis oculi muscles to the lateral orbital wall and zygoma, which forms the posterior orbital wall.^3,4 The lateral canthal tendon is located beneath the lateral canthus and is comprised of the inferior and superior crus, which attaches to the inner aspect of the lateral orbital wall, forming a structure called Whitnall’s tubercle.^3,4

Other than globe injuries, the most common findings in patients with orbital trauma are periocular lacerations (96%), orbital fractures (16%), and retrobulbar hemorrhage (8%).⁵ The most common cause of retrobulbar hemorrhage is ocular trauma, but it is also observed in facial fractures, orbital surgery, retrobulbar injections, venous anomalies, atherosclerosis, intraorbital aneurysm of the ophthalmic artery, lacerated ophthalmic artery, hypertension, hemophilia, leukemia, von Willebrand disease, and straining.^3,6,7

In retrobulbar hemorrhage, an increased pressure in the orbital space can lead to optic nerve compression and vascular compromise.⁶ Important alternative diagnoses to consider include orbital cellulitis, orbital fracture, and globe rupture.³ Retrobulbar hemorrhage should be suspected in the clinical setting of exophthalmos, proptosis, diffuse subconjunctival hemorrhage, pain, visual loss or diplopia, periorbital edema, partial or complete ophthalmoplegia, resistance to retropulsion, increased IOP, a blanched ophthalmic artery on funduscopic examination, and an afferent pupillary defect.^3,4,8,9 Less commonly, periorbital crepitus and infraorbital hypoesthesia can be appreciated.³

If a patient with a retrobulbar hemorrhage is experiencing diminished vision, an emergent lateral canthotomy should be attempted. Retrobulbar hemorrhage can be difficult to diagnose in the setting of trauma. There can be damage to the optic nerve with associated edema and vision loss that is not associated with a retrobulbar hemorrhage and does not require a lateral canthotomy.^3,7 A dedicated CT scan of the orbits can aid in the diagnosis, but treatment should not be delayed.⁸

Patients with retrobulbar hemorrhage may initially present to the ED with intact visual acuity, but as the pressure behind the globe increases, vision will diminish.³ Although the medical literature has not established a definitive timeframe, it is believed that permanent visual compromise develops between 1 to 3 hours after ischemia develops.⁶ Animal studies show that visual loss due to central retinal artery ischemia may be reversible up to 100 minutes.³

Not all cases of retrobulbar hemorrhage are associated with vision loss. In patients without diminished vision, conservative treatments such as bed rest, elevation of the head of the bed, ice packs, analgesia, lowering BP, and sedatives should be attempted first.⁵ Acetazolamide and mannitol can also be considered in consultation with an ophthalmologist.

Pneumo-orbitum

The presence of pneumo-orbitum should alert the clinician to either a communication with a paranasal sinus, a gas-forming organism, or (rarely) Munchausen syndrome.¹⁰ Unlike most case presentations, most causes of pneumo-orbitum do not involve OCS and are self-limited.¹¹ Traumatic pneumo-orbitum without OCS has been reported in the literature.^12-15 However, traumatic tension pneumo-orbitum is rare.^12-16 One case report involved an elderly man with an orbital floor fracture who developed recurrent tension pneumo-orbitum after blowing his nose while intoxicated.¹² Another case involved a boy with tension pneumo-orbitum that required surgical decompression.¹⁶

In a patient who has experienced trauma, the combination of proptosis, elevated IOP, and vision loss likely represent a retrobulbar hematoma or OCS. A lateral canthotomy can help relieve IOP from either condition.^17,18 Orbital compartment syndrome can be caused by edema, emphysema, and caroticocavernous fistula, leading to increased orbital pressure and decreased perfusion.^17,18

In a review of 10 trauma patients with OCS, all cases were intubated due to the severity of the head trauma, and all had OCS due to edema.¹⁷ In a review of eight trauma patients with OCS, all had eye pain, reduced visual acuity, and proptosis.¹⁸ Most of the patients had periorbital edema, ophthalmoparesis, a relative afferent pupillary defect (as compared to a fixed and dilated pupil), and chemosis.^18,19 All of the patients with OCS required cantholysis or a lateral canthotomy.¹⁸

Lateral Canthotomy

Although EPs rarely perform lateral canthotomy, knowledge of this procedure is important, because it can prevent vision loss in the appropriate clinical setting. To perform a lateral canthotomy, the area around the affected eye is cleaned with saline irrigation.⁴ One percent or 2% lidocaine with epinephrine is then injected into the lateral canthus of the affected eye.^4,10 A straight hemostat is applied between the upper and lower lids, producing a crush injury along the site of local anesthesia for 1 to 2 minutes.^3,4,10 This is done to reduce the risk of bleeding by devitalizing the tissue.⁴ Straight scissors are then used to make a 1-cm horizontal incision from the lateral canthal tendon to the lateral orbital rim.⁴ This initial incision exposes the orbicularis muscle, orbital septum, palpebral conjunctiva, and an area called Eisler’s pocket that sits anterior to the lateral canthal tendon.³

Cantholysis can then be performed by blunt dissection.¹⁰ The inferior crus of the lateral canthus is identified either visually or by palpation, and a 1- to 2-cm inferior-posterior cut of the inferior crus accomplishes the lateral canthotomy.^3-4 After cutting the inferior crus, the lower lid should be pulled away easily, and if this does not occur, repeated attempts at cutting the inferior crus should be made.³ Pulling the lower eyelid down and away from the lateral orbital rim separates the skin and conjunctiva, aiding in visualization.⁴

After cutting the inferior crus, only a small amount of blood or air typically is expressed, but this is usually enough to prevent vision loss.³ When the procedure is performed correctly, the practitioner should be able to palpate a difference in the pressure of the globe, and tonography will show a reduced IOP. If the ocular pressure is still significantly elevated, the physician can proceed to cut the superior canthus of the lateral canthal tendon in a manner similar to cutting the inferior crus of the tendon.⁴ After the procedure is performed, urgent ophthalmologic consultation is required.

The risks of performing a lateral canthotomy include mechanical injury, hemorrhage, and infection.⁴ The incision from a lateral canthotomy generally does not need suturing and will heal without significant scarring.⁴ If the scissors are aimed superiorly instead of inferiorly for the inferior crus of the lateral canthal tendon, there is risk of injuring the levator aponeurosis leading to ptosis, as well as a small risk of injury to the lacrimal gland and lacrimal artery.³

Conclusion

Our patient demonstrates a case of traumatic OCS, a vision-threatening medical condition that requires rapid diagnosis and lateral canthotomy to lower IOP and reduce the risk of permanent vision loss. While an orbital CT scan may assist in confirming the diagnosis, treatment of IOP should not be delayed.

Traumatic eye injuries ranging from mild corneal abrasions to penetrating globe injuries are commonly seen in the ED, and ocular trauma accounts for nearly 1% of all complaints in the ED.¹ Up to 29% of facial fractures have associated eye injuries.² Emergency physicians (EPs) must be aware of possible eye injuries, including traumatic vision loss, and the indicators for emergent interventions.

Tension pneumo-orbitum following facial trauma is rarely reported. We present a case of orbital compartment syndrome (OCS) in an elderly woman who sustained an orbital floor fracture and required emergent lateral canthotomy to preserve vision.

Case

A 76-year-old woman presented to the ED for evaluation of pain, swelling, and loss of vision in the right eye. She said she had been sitting in a chair tying her shoes when she lost her balance and fell forward, striking her head and the right side of her face against the floor. She experienced no loss of consciousness and denied any neck pain, jaw pain, or dizziness. She also denied any chest pain, shortness of breath, weakness, or loss of function in either her arms or legs. She did, however, note a small nosebleed that had stopped before she arrived at the ED. The patient’s primary complaint was a possible nasal bone fracture.

Her medical history was significant for hypertension and coronary artery disease. Her medications include amitriptyline, an antihistamine, aspirin, clopidogrel, diltiazem, folic acid, furosemide, hydralazine, levothyroxine, prednisone, and zolpidem. She stated that she was allergic to amoxicillin and sulfa drugs.

The patient’s vital signs at presentation were: blood pressure (BP), 193/82 mm Hg; heart rate, 71 beats/minute; respiratory rate, 16 breaths/minute; and temperature, 97°F. She was alert, oriented, and in no distress. Her head and neck examination showed no scalp lacerations or swelling. There was, however, significant swelling and ecchymosis around the right eye and swelling and ecchymosis around the nose, with dried blood in both nares. No septal hematoma was present. The patient had tenderness to palpation over the infraorbital area and nose. No gross facial instability was present, and Battle sign was not appreciated. No jaw or dental abnormalities were noted.

The patient’s right pupil was fixed and dilated, and she could not perceive light. She did have upward and lateral movement of the eye, but was unable to look down. A minimal amount of proptosis was noted. Her intraocular pressure (IOP) was elevated at 54 mm Hg (normal range, 10-20 mm Hg). The remainder of the examination, including the neurological examination, was unremarkable.

The patient received emergent head and facial computed tomography (CT) scans. The head CT showed no acute intracranial hemorrhage, mass, or infarct. The facial CT was read as a right orbital floor fracture with intraorbital air, and a right maxillary sinus hematoma. Laboratory evaluation revealed a hematocrit of 38% and a platelet count of 544,000/mcL (normal range, 150,000-450,000/mcL). The prothrombin time was 10.9 seconds (normal range, 11-13.5 seconds); the international normalized ratio was 0.8 (normal range, 0.8-1.1); and the partial thromboplastin time was 22.5 seconds (normal range, 25-35 seconds).

Because the patient was at risk for permanent visual impairment due to increased IOP from the injury, a lateral canthotomy was immediately performed. A small amount of air was released, and the proptosis was notably reduced.

At this point, the ophthalmologist arrived and used an 18-gauge needle to explore the retrobulbar space. Two pockets of air were released, which markedly reduced the tactile pressure of the globe. Repeat tonography of the globe was 28 mm Hg. The wound was left open to drain, and the patient was started on azithromycin. She was discharged home to follow up with ophthalmology.

The patient presented to the ED 2 months later for an unrelated condition. At that time, she reported a complete return of her vision with no deficits and no noticeable scarring around the eye.

Discussion

The orbit is an enclosed space, bordered by bone laterally and posteriorly—the orbital septa superiorly and inferiorly, and the globe anteriorly.³ The lateral canthus is a combined tendon-ligament that helps attach the tarsal plates of the lids and the orbicularis oculi muscles to the lateral orbital wall and zygoma, which forms the posterior orbital wall.^3,4 The lateral canthal tendon is located beneath the lateral canthus and is comprised of the inferior and superior crus, which attaches to the inner aspect of the lateral orbital wall, forming a structure called Whitnall’s tubercle.^3,4

Other than globe injuries, the most common findings in patients with orbital trauma are periocular lacerations (96%), orbital fractures (16%), and retrobulbar hemorrhage (8%).⁵ The most common cause of retrobulbar hemorrhage is ocular trauma, but it is also observed in facial fractures, orbital surgery, retrobulbar injections, venous anomalies, atherosclerosis, intraorbital aneurysm of the ophthalmic artery, lacerated ophthalmic artery, hypertension, hemophilia, leukemia, von Willebrand disease, and straining.^3,6,7

In retrobulbar hemorrhage, an increased pressure in the orbital space can lead to optic nerve compression and vascular compromise.⁶ Important alternative diagnoses to consider include orbital cellulitis, orbital fracture, and globe rupture.³ Retrobulbar hemorrhage should be suspected in the clinical setting of exophthalmos, proptosis, diffuse subconjunctival hemorrhage, pain, visual loss or diplopia, periorbital edema, partial or complete ophthalmoplegia, resistance to retropulsion, increased IOP, a blanched ophthalmic artery on funduscopic examination, and an afferent pupillary defect.^3,4,8,9 Less commonly, periorbital crepitus and infraorbital hypoesthesia can be appreciated.³

If a patient with a retrobulbar hemorrhage is experiencing diminished vision, an emergent lateral canthotomy should be attempted. Retrobulbar hemorrhage can be difficult to diagnose in the setting of trauma. There can be damage to the optic nerve with associated edema and vision loss that is not associated with a retrobulbar hemorrhage and does not require a lateral canthotomy.^3,7 A dedicated CT scan of the orbits can aid in the diagnosis, but treatment should not be delayed.⁸

Patients with retrobulbar hemorrhage may initially present to the ED with intact visual acuity, but as the pressure behind the globe increases, vision will diminish.³ Although the medical literature has not established a definitive timeframe, it is believed that permanent visual compromise develops between 1 to 3 hours after ischemia develops.⁶ Animal studies show that visual loss due to central retinal artery ischemia may be reversible up to 100 minutes.³

Not all cases of retrobulbar hemorrhage are associated with vision loss. In patients without diminished vision, conservative treatments such as bed rest, elevation of the head of the bed, ice packs, analgesia, lowering BP, and sedatives should be attempted first.⁵ Acetazolamide and mannitol can also be considered in consultation with an ophthalmologist.

Pneumo-orbitum

The presence of pneumo-orbitum should alert the clinician to either a communication with a paranasal sinus, a gas-forming organism, or (rarely) Munchausen syndrome.¹⁰ Unlike most case presentations, most causes of pneumo-orbitum do not involve OCS and are self-limited.¹¹ Traumatic pneumo-orbitum without OCS has been reported in the literature.^12-15 However, traumatic tension pneumo-orbitum is rare.^12-16 One case report involved an elderly man with an orbital floor fracture who developed recurrent tension pneumo-orbitum after blowing his nose while intoxicated.¹² Another case involved a boy with tension pneumo-orbitum that required surgical decompression.¹⁶

In a patient who has experienced trauma, the combination of proptosis, elevated IOP, and vision loss likely represent a retrobulbar hematoma or OCS. A lateral canthotomy can help relieve IOP from either condition.^17,18 Orbital compartment syndrome can be caused by edema, emphysema, and caroticocavernous fistula, leading to increased orbital pressure and decreased perfusion.^17,18

In a review of 10 trauma patients with OCS, all cases were intubated due to the severity of the head trauma, and all had OCS due to edema.¹⁷ In a review of eight trauma patients with OCS, all had eye pain, reduced visual acuity, and proptosis.¹⁸ Most of the patients had periorbital edema, ophthalmoparesis, a relative afferent pupillary defect (as compared to a fixed and dilated pupil), and chemosis.^18,19 All of the patients with OCS required cantholysis or a lateral canthotomy.¹⁸

Lateral Canthotomy

Although EPs rarely perform lateral canthotomy, knowledge of this procedure is important, because it can prevent vision loss in the appropriate clinical setting. To perform a lateral canthotomy, the area around the affected eye is cleaned with saline irrigation.⁴ One percent or 2% lidocaine with epinephrine is then injected into the lateral canthus of the affected eye.^4,10 A straight hemostat is applied between the upper and lower lids, producing a crush injury along the site of local anesthesia for 1 to 2 minutes.^3,4,10 This is done to reduce the risk of bleeding by devitalizing the tissue.⁴ Straight scissors are then used to make a 1-cm horizontal incision from the lateral canthal tendon to the lateral orbital rim.⁴ This initial incision exposes the orbicularis muscle, orbital septum, palpebral conjunctiva, and an area called Eisler’s pocket that sits anterior to the lateral canthal tendon.³

Cantholysis can then be performed by blunt dissection.¹⁰ The inferior crus of the lateral canthus is identified either visually or by palpation, and a 1- to 2-cm inferior-posterior cut of the inferior crus accomplishes the lateral canthotomy.^3-4 After cutting the inferior crus, the lower lid should be pulled away easily, and if this does not occur, repeated attempts at cutting the inferior crus should be made.³ Pulling the lower eyelid down and away from the lateral orbital rim separates the skin and conjunctiva, aiding in visualization.⁴

After cutting the inferior crus, only a small amount of blood or air typically is expressed, but this is usually enough to prevent vision loss.³ When the procedure is performed correctly, the practitioner should be able to palpate a difference in the pressure of the globe, and tonography will show a reduced IOP. If the ocular pressure is still significantly elevated, the physician can proceed to cut the superior canthus of the lateral canthal tendon in a manner similar to cutting the inferior crus of the tendon.⁴ After the procedure is performed, urgent ophthalmologic consultation is required.

The risks of performing a lateral canthotomy include mechanical injury, hemorrhage, and infection.⁴ The incision from a lateral canthotomy generally does not need suturing and will heal without significant scarring.⁴ If the scissors are aimed superiorly instead of inferiorly for the inferior crus of the lateral canthal tendon, there is risk of injuring the levator aponeurosis leading to ptosis, as well as a small risk of injury to the lacrimal gland and lacrimal artery.³

Conclusion

Our patient demonstrates a case of traumatic OCS, a vision-threatening medical condition that requires rapid diagnosis and lateral canthotomy to lower IOP and reduce the risk of permanent vision loss. While an orbital CT scan may assist in confirming the diagnosis, treatment of IOP should not be delayed.

Traumatic eye injuries ranging from mild corneal abrasions to penetrating globe injuries are commonly seen in the ED, and ocular trauma accounts for nearly 1% of all complaints in the ED.¹ Up to 29% of facial fractures have associated eye injuries.² Emergency physicians (EPs) must be aware of possible eye injuries, including traumatic vision loss, and the indicators for emergent interventions.

Tension pneumo-orbitum following facial trauma is rarely reported. We present a case of orbital compartment syndrome (OCS) in an elderly woman who sustained an orbital floor fracture and required emergent lateral canthotomy to preserve vision.

Case

A 76-year-old woman presented to the ED for evaluation of pain, swelling, and loss of vision in the right eye. She said she had been sitting in a chair tying her shoes when she lost her balance and fell forward, striking her head and the right side of her face against the floor. She experienced no loss of consciousness and denied any neck pain, jaw pain, or dizziness. She also denied any chest pain, shortness of breath, weakness, or loss of function in either her arms or legs. She did, however, note a small nosebleed that had stopped before she arrived at the ED. The patient’s primary complaint was a possible nasal bone fracture.

Her medical history was significant for hypertension and coronary artery disease. Her medications include amitriptyline, an antihistamine, aspirin, clopidogrel, diltiazem, folic acid, furosemide, hydralazine, levothyroxine, prednisone, and zolpidem. She stated that she was allergic to amoxicillin and sulfa drugs.

The patient’s vital signs at presentation were: blood pressure (BP), 193/82 mm Hg; heart rate, 71 beats/minute; respiratory rate, 16 breaths/minute; and temperature, 97°F. She was alert, oriented, and in no distress. Her head and neck examination showed no scalp lacerations or swelling. There was, however, significant swelling and ecchymosis around the right eye and swelling and ecchymosis around the nose, with dried blood in both nares. No septal hematoma was present. The patient had tenderness to palpation over the infraorbital area and nose. No gross facial instability was present, and Battle sign was not appreciated. No jaw or dental abnormalities were noted.

The patient’s right pupil was fixed and dilated, and she could not perceive light. She did have upward and lateral movement of the eye, but was unable to look down. A minimal amount of proptosis was noted. Her intraocular pressure (IOP) was elevated at 54 mm Hg (normal range, 10-20 mm Hg). The remainder of the examination, including the neurological examination, was unremarkable.

The patient received emergent head and facial computed tomography (CT) scans. The head CT showed no acute intracranial hemorrhage, mass, or infarct. The facial CT was read as a right orbital floor fracture with intraorbital air, and a right maxillary sinus hematoma. Laboratory evaluation revealed a hematocrit of 38% and a platelet count of 544,000/mcL (normal range, 150,000-450,000/mcL). The prothrombin time was 10.9 seconds (normal range, 11-13.5 seconds); the international normalized ratio was 0.8 (normal range, 0.8-1.1); and the partial thromboplastin time was 22.5 seconds (normal range, 25-35 seconds).

Because the patient was at risk for permanent visual impairment due to increased IOP from the injury, a lateral canthotomy was immediately performed. A small amount of air was released, and the proptosis was notably reduced.

At this point, the ophthalmologist arrived and used an 18-gauge needle to explore the retrobulbar space. Two pockets of air were released, which markedly reduced the tactile pressure of the globe. Repeat tonography of the globe was 28 mm Hg. The wound was left open to drain, and the patient was started on azithromycin. She was discharged home to follow up with ophthalmology.

The patient presented to the ED 2 months later for an unrelated condition. At that time, she reported a complete return of her vision with no deficits and no noticeable scarring around the eye.

Discussion

The orbit is an enclosed space, bordered by bone laterally and posteriorly—the orbital septa superiorly and inferiorly, and the globe anteriorly.³ The lateral canthus is a combined tendon-ligament that helps attach the tarsal plates of the lids and the orbicularis oculi muscles to the lateral orbital wall and zygoma, which forms the posterior orbital wall.^3,4 The lateral canthal tendon is located beneath the lateral canthus and is comprised of the inferior and superior crus, which attaches to the inner aspect of the lateral orbital wall, forming a structure called Whitnall’s tubercle.^3,4

Other than globe injuries, the most common findings in patients with orbital trauma are periocular lacerations (96%), orbital fractures (16%), and retrobulbar hemorrhage (8%).⁵ The most common cause of retrobulbar hemorrhage is ocular trauma, but it is also observed in facial fractures, orbital surgery, retrobulbar injections, venous anomalies, atherosclerosis, intraorbital aneurysm of the ophthalmic artery, lacerated ophthalmic artery, hypertension, hemophilia, leukemia, von Willebrand disease, and straining.^3,6,7

In retrobulbar hemorrhage, an increased pressure in the orbital space can lead to optic nerve compression and vascular compromise.⁶ Important alternative diagnoses to consider include orbital cellulitis, orbital fracture, and globe rupture.³ Retrobulbar hemorrhage should be suspected in the clinical setting of exophthalmos, proptosis, diffuse subconjunctival hemorrhage, pain, visual loss or diplopia, periorbital edema, partial or complete ophthalmoplegia, resistance to retropulsion, increased IOP, a blanched ophthalmic artery on funduscopic examination, and an afferent pupillary defect.^3,4,8,9 Less commonly, periorbital crepitus and infraorbital hypoesthesia can be appreciated.³

If a patient with a retrobulbar hemorrhage is experiencing diminished vision, an emergent lateral canthotomy should be attempted. Retrobulbar hemorrhage can be difficult to diagnose in the setting of trauma. There can be damage to the optic nerve with associated edema and vision loss that is not associated with a retrobulbar hemorrhage and does not require a lateral canthotomy.^3,7 A dedicated CT scan of the orbits can aid in the diagnosis, but treatment should not be delayed.⁸

Patients with retrobulbar hemorrhage may initially present to the ED with intact visual acuity, but as the pressure behind the globe increases, vision will diminish.³ Although the medical literature has not established a definitive timeframe, it is believed that permanent visual compromise develops between 1 to 3 hours after ischemia develops.⁶ Animal studies show that visual loss due to central retinal artery ischemia may be reversible up to 100 minutes.³

Not all cases of retrobulbar hemorrhage are associated with vision loss. In patients without diminished vision, conservative treatments such as bed rest, elevation of the head of the bed, ice packs, analgesia, lowering BP, and sedatives should be attempted first.⁵ Acetazolamide and mannitol can also be considered in consultation with an ophthalmologist.

Pneumo-orbitum

The presence of pneumo-orbitum should alert the clinician to either a communication with a paranasal sinus, a gas-forming organism, or (rarely) Munchausen syndrome.¹⁰ Unlike most case presentations, most causes of pneumo-orbitum do not involve OCS and are self-limited.¹¹ Traumatic pneumo-orbitum without OCS has been reported in the literature.^12-15 However, traumatic tension pneumo-orbitum is rare.^12-16 One case report involved an elderly man with an orbital floor fracture who developed recurrent tension pneumo-orbitum after blowing his nose while intoxicated.¹² Another case involved a boy with tension pneumo-orbitum that required surgical decompression.¹⁶

In a patient who has experienced trauma, the combination of proptosis, elevated IOP, and vision loss likely represent a retrobulbar hematoma or OCS. A lateral canthotomy can help relieve IOP from either condition.^17,18 Orbital compartment syndrome can be caused by edema, emphysema, and caroticocavernous fistula, leading to increased orbital pressure and decreased perfusion.^17,18

In a review of 10 trauma patients with OCS, all cases were intubated due to the severity of the head trauma, and all had OCS due to edema.¹⁷ In a review of eight trauma patients with OCS, all had eye pain, reduced visual acuity, and proptosis.¹⁸ Most of the patients had periorbital edema, ophthalmoparesis, a relative afferent pupillary defect (as compared to a fixed and dilated pupil), and chemosis.^18,19 All of the patients with OCS required cantholysis or a lateral canthotomy.¹⁸

Lateral Canthotomy

Although EPs rarely perform lateral canthotomy, knowledge of this procedure is important, because it can prevent vision loss in the appropriate clinical setting. To perform a lateral canthotomy, the area around the affected eye is cleaned with saline irrigation.⁴ One percent or 2% lidocaine with epinephrine is then injected into the lateral canthus of the affected eye.^4,10 A straight hemostat is applied between the upper and lower lids, producing a crush injury along the site of local anesthesia for 1 to 2 minutes.^3,4,10 This is done to reduce the risk of bleeding by devitalizing the tissue.⁴ Straight scissors are then used to make a 1-cm horizontal incision from the lateral canthal tendon to the lateral orbital rim.⁴ This initial incision exposes the orbicularis muscle, orbital septum, palpebral conjunctiva, and an area called Eisler’s pocket that sits anterior to the lateral canthal tendon.³

Cantholysis can then be performed by blunt dissection.¹⁰ The inferior crus of the lateral canthus is identified either visually or by palpation, and a 1- to 2-cm inferior-posterior cut of the inferior crus accomplishes the lateral canthotomy.^3-4 After cutting the inferior crus, the lower lid should be pulled away easily, and if this does not occur, repeated attempts at cutting the inferior crus should be made.³ Pulling the lower eyelid down and away from the lateral orbital rim separates the skin and conjunctiva, aiding in visualization.⁴

After cutting the inferior crus, only a small amount of blood or air typically is expressed, but this is usually enough to prevent vision loss.³ When the procedure is performed correctly, the practitioner should be able to palpate a difference in the pressure of the globe, and tonography will show a reduced IOP. If the ocular pressure is still significantly elevated, the physician can proceed to cut the superior canthus of the lateral canthal tendon in a manner similar to cutting the inferior crus of the tendon.⁴ After the procedure is performed, urgent ophthalmologic consultation is required.

The risks of performing a lateral canthotomy include mechanical injury, hemorrhage, and infection.⁴ The incision from a lateral canthotomy generally does not need suturing and will heal without significant scarring.⁴ If the scissors are aimed superiorly instead of inferiorly for the inferior crus of the lateral canthal tendon, there is risk of injuring the levator aponeurosis leading to ptosis, as well as a small risk of injury to the lacrimal gland and lacrimal artery.³

Conclusion

Our patient demonstrates a case of traumatic OCS, a vision-threatening medical condition that requires rapid diagnosis and lateral canthotomy to lower IOP and reduce the risk of permanent vision loss. While an orbital CT scan may assist in confirming the diagnosis, treatment of IOP should not be delayed.

Orlando Regional Medical Center (ORMC) is an urban, academic, Level 1 trauma center with an ED that treats in excess of 85,000 patients each year. There are more than 4,500 annual trauma admissions, including penetrating and blunt mechanism injuries. We have a 3-year emergency medicine (EM) residency program, originally established in 1986, that now has 14 residents per year. The events that we experienced on the early morning of June 12, 2016 were tragic and unexpected and tested our community, our teams, and our organization. The following is a description of activity perspectives, personal reflections and feelings, and important lessons learned from which other EDs may benefit.

Prehospital/Rescue Period

The prehospital approach to a mass-casualty incident (MCI) caused by gunfire has changed significantly over the last decade, with lessons gleaned from the experience of military and domestic attacks. The Orange County (Florida) Emergency Medical Services (EMS) System, including the agencies involved in the response to the June 12, 2016 Pulse nightclub shooting incident (Orlando Fire Department, Rural Metro Ambulance, and Orange County Fire Rescue), have trained specifically on the evolving priorities during an active shooter incident. This includes targeted hemorrhage control, swift extrication, minimal interventions, and immediate transport to the appropriate receiving center. In June 2015, 1 year prior to the Pulse nightclub shooting, a protocol variance was written by medical directors, explaining that “EMS providers may engage in initial patient care with only the supplies deemed absolutely necessary for rapid evaluation and removal into a safe triage zone.” This variance applies when there is an active shooter scenario. In addition, in 2014, 2015, and 2016, we conducted large scale, multiagency community exercises, encompassing shooting/active shooter scenarios and drills.

On June 12, 2016, EMS units were on scene of the Pulse nightclub in downtown Orlando less than 5 minutes after shooting began. It became immediately obvious that additional resources would be necessary. Soon after the incident, an MCI alert was activated from the Orlando Fire Department Communications Center, utilizing a software system to notify area hospitals and the medical directors that up to 20 patients had been shot, and requesting status on bed availability. Christopher L. Hunter, MD, PhD, one of our associate EMS medical directors, was working in the ED at a hospital several miles away from the incident and began coordinating efforts to distribute patients to the appropriate destination via radio and phone communication between the scene, the communications center, and the trauma center.

On scene, a group of law enforcement officers were engaging the shooter while others assisted in extracting victims from the club and surrounding area. Injured victims were brought to a casualty collection point, under cover, across the street and were transported as units became available. Initially, law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload. Per previous training, minimal interventions were performed, and unlike standard procedure, EMS could offer no prearrival report to the hospital. The decision was made to triage only patients meeting Florida’s state trauma alert criteria to ORMC, and funnel other patients to nearby nontrauma centers. Dr Hunter attempted to notify the hospitals of patients as they were transported off the scene; however, the extremely short transport times made this process difficult.

Over the course of the incident, on-scene commands designated a casualty collection point, a transport unit staging area, and a hospital liaison. Emergency medical service responders cooperated with law enforcement to transport injured patients throughout the response. By the end of the event, nearly 100 EMS providers utilizing dozens of vehicles had responded to the scene.

The ED Period

The overnight shift of Saturday, June 11 was slower than usual in the ORMC ED, and triage housed the typical Saturday-night complaints. One of our mid-level providers, Brian Clayton, ARNP, worked in the fast track pod treating lower acuity illnesses, while the four senior residents discussed who might receive the honor of leaving early. Even the senior attending, Gary A. Parrish, MD, wrapped up his patients and was ready to leave right on time. The 11:00 pm to 7:00 am attending, Kathryn  J. Bondani, MD, was looking forward to an easy shift with four graduating senior residents. We had just called in an order from a popular nearby sandwich shop when suddenly, a slew of police cars flew past the hospital—not unusual given our proximity to downtown. The radio squawked “Multiple gunshots wounds en route.” Someone said “a club downtown got shot up.” In anticipation of multiple patient arrivals, resident Amanda M. Stone, MD, and the attending hurried to the trauma/ressuscitation bay. Another resident, Amanda F. Tarkowski, MD, called the trauma attending to rally his team downstairs, informing him that “A club downtown has a shooter and we have multiple patients with a 2-minute ETA.” Multiple gunshot wounds (GSWs) at once is not unusual for our Level 1 trauma center.

The first patient arrived shortly after 2:00 am and had multiple GSWs to the abdomen, but was awake and talking. He was mildly tachycardic, but his blood pressure (BP) was stable. We all gaped at the fist-sized wound on his back—some of us had never seen a GSW like this before. It was apparent that he needed to go to the operating room, but before preparations could be made, three more patients rolled into the ED. Instead of our usual organized, methodical EMS report, these patients were dropped off by a police pickup truck and rolled in on our own stretchers by nurses and technicians. Soon, all six of our trauma bays were filled with critical patients. Christopher H. Ponder, MD, recalled, “I heard an overhead page for ‘all available trauma nurses to the trauma bay’ shortly followed by a more concerned-sounding ‘all available staff to the trauma bay.’” All four senior EM residents, both EM attendings, the trauma attending, four trauma residents, multiple ED nurses, technicians, and various ancillary staff quickly descended on the patients. Chest tubes were placed, and multiple patients were intubated. Several thoracotomies were performed at the initial point when the team was unaware of the exact number of patients who would ultimately follow. Blood bags were hung and tranexamic acid was administered liberally. Unfortunately, some of these initial attempts were unsuccessful, as the first wave contained the most critically injured patients.

We barely had time to reflect on the dead as more patients filled the hallways. In the midst of all of this, triage decisions came quickly—awake and talking patients with an acceptable BP were moved out of the trauma bay in favor of less stable patients. Intubation and chest-tube placement decisions were made instantly. There was no time for routine X-rays or laboratory evaluation. Nurses, technicians, and doctors crowded the trauma bay desperately trying to stabilize the critically injured. Vital signs were taken manually. Dr Ponder called his colleague Thomas N. Smith, MD, who was also a graduating senior EM resident, and who happened to be staffing the children’s ED across the street that night. “Is there any way you can make it over here right now?” he shouted into the phone. Dr Smith quickly grabbed several trauma supplies and hitched a ride with security to the ORMC ED to assist. He was confronted with the scene of the previously mentioned “first wave” and grabbed an ultrasound machine to help triage these unfortunate patients. In addition to Dr Smith, unit clerks continued making calls to additional off-duty medical, nursing, and support staff. Critical care attendings and fellows responded from upstairs to assist in the ED. The Hospital Incident Command System (HICS) was initiated to provide hospital and corporate coordination of services. Timothy B. Bullard, MD, another EM attending physician and medical staff director of HICS, was en route to the ED to assist in the response.

Amidst the overwhelming mass of mortally and critically wounded patients, we were told stories of terror from just down the road. The sense of horror was almost contagious, and we all wondered if the violence would spread to the hospital.

About an hour into the ordeal, we heard another page overhead “Code Silver, ED Triage. Code Silver, ED Triage.” Everyone in the trauma bay froze. We heard someone shout from the hallway “Shots fired in triage!” After a few seconds, those nearest the trauma bay doors pushed them shut. One of the trauma surgeons shouted, “Keep caring for your patients, push the portable X-ray machines in front of the doors.” That is exactly what happened, and we worked in the barricaded trauma room for the longest few minutes of the night. We would later learn that this report was false, but fearing for our own lives as well as the lives of our patients is an experience that few, if any, of us had previously been through. The fact that we continued to work in such a situation illustrates everyone’s dedication to their patients and mission.

After the first wave of patients, it was clear that reassessing patients was now our greatest challenge. There were multiple patients with stable vital signs but who had GSWs to the abdomen, pelvis, and thorax and required surgery. Having realized that the ultrasound machine and focused assessment with sonography for trauma (FAST) examinations were the most practical rapid imaging modality, Drs Tarkowski, Ponder, and Smith grabbed the machine and went from room to room repeating the FAST examinations, vital signs, and assessments for missed wounds. A portable computer allowed us to order X-ray orders for patients with extremity wounds. Several patients who initially had negative FASTs had a repeat examination that was positive for free fluid. The operating room triage list shuffled based on these examinations.

At this point, there seemed to be a never-ending list of “Doe” names on the electronic medical record (EMR) tracking board. Tracking the location of patients was a dynamic process, and updating the tracking board was difficult. Patients were continually cycled in and out of the trauma bay, shuffled in and out of treatment rooms, lined up in the hallways, and transported up to the intensive care unit (ICU). Some of those “Doe” names belonged to patients who had succumbed to their injuries. Some patients had empty, bloody charts next to them on their stretcher. Every patient had a wristband. Dr Tarkowski improvised a rapid documentation system using quarter sheets of scrap paper that were taped either to the stretcher or door with a patient name, brief list of injuries, FAST examination result, pending tests, and medications given. This system was an efficient way of identifying which patients had been evaluated, what had been done, and what was pending.

While we were “rounding” on our patients, down the street, law enforcement had broken down the club’s wall, and a second wave of patients began to arrive. Two residents completed the secondary evaluations while the other three resuscitated new patients. The second wave seemed like a repeat of the first. Several extremity-only injuries were triaged directly to the hallways to be seen by the two residents outside of the trauma bay. By this time, the orthopedic surgery service had come down to the ED and was washing out wounds, splinting, and making plans for surgery. The internal medicine service and the medical critical care team were helping reassess patients as well.

There were many emotional moments. Dr Ponder remembered, “One of the first few patients I saw was pulseless, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’ That’s when I realized the gravity of our situation. For almost 2 hours, each resident cycled through patients.” Dr Stone recounted, “I just went down the line of patients, from head of the bed to head of the bed, some patients still on EMS stretchers, intubating many of them. It was surreal to see that many severely injured in one place.” Tory L. Weatherford, MD, recalled, “It was controlled chaos. My training kicked in, and it became about just trying to do anything possible to help.”

Dr Bondani, the overnight attending, said she does not remember many specifics from the event. “Faces and injuries blurred together. I remember looking in one young man’s eyes and telling him, ‘We are going to help you, just hang in there,’ and telling another panicking woman, ‘You’re talking, you can feel pain, you’re alive. Calm down.’ It was organized chaos as we swept from patient to patient moving as quickly as possible. Your training kicks in and you do what needs to be done in the moment.”

We were fortunate to have the EM team we did, and to be in the place that we were. On duty, we had five senior graduating residents, essentially with attending-level skills and training, who had been together since day one. “We gave everything we had; there was no time to stop. We went where our hands could be helpful—it didn’t matter if it was your traditional role or not,” said Dr Weatherford.

Dr Tarkowski remembered what it was like leaving the walls of the ED later that morning. “Leaving the hospital didn’t feel like a success. We knew the work we did was good, that we did everything we could, but it didn’t feel like it. It felt heavy. It felt empty.” Afterward, the emotional toll set in. We gathered up the names of the deceased and looked at a status board littered with “Doe” names, and we tried hard not to break down at the violence and the pain we witnessed.

Immediate Recovery Period (Prehospital Setting)

In the aftermath of the initial rescue operation, stabilization of injured victims, and demobilization of resources, a second “event” unfolded—hundreds of family members flooded to ORMC looking for unaccounted loved ones. At this point, there were dozens of deceased and critically injured patients who remained unidentified, and addressing the needs of both the victims and the families was becoming overwhelming. With the cooperation of federal, state, county, city, and private resources, a family reunification center (FRC; a family staging area/family reception center) was created and managed initially within the hospital. At this site, grief counselors, victim advocates, law enforcement and medical examiner’s officials, hospital chaplains, and translators gathered with the loved ones of those missing to synchronize efforts to identify and reunite them. The Emergency Operations Center quickly created a telephone hotline and Web site to guide those in need to this resource. Food and housing for those in need were provided by the generosity of our community—which cannot be overstated in the wake of this tragedy. As days passed, the FRC transitioned to a new location as the Orlando United Assistance Center, and will continue to serve as a navigation point for those who are and will be affected by the event for months to come.

Hospital Incident Command System

The HICS was activated shortly past 3:00 am, just after the initial wave of victims flooded our ED and the gravity of the situation became apparent. The ED and trauma services were already near full staff due to timing, rapid response, and communication between the traumatologists, as well as a bit of luck. Because of the time of the disaster, our normal notification process for incident command and all personnel was severely limited. In retrospect, this turned out to be a blessing. While everyone who normally would respond to HICS was not available, individuals serving in key positions were reached by personal phone calls and were on-site quickly. One of the main functions of HICS is to control the internal chaos that arises when a disaster occurs and all personnel want to assist in some manner. We have spent hours during drills crafting communications that target key personnel necessary to meet the mission, while controlling well-intentioned but unnecessary personnel. In our drills, this is not an issue because everyone knows the exercise is not reality; however, in a real disaster, everyone wants to help. This was confirmed by the guilt that so many of our team members expressed at not being involved that Sunday.

With an initial skeleton crew in incident command, it was easy to focus on the immediate needs of patient care. The strong leadership and cool heads of our incident command leadership led to rapid role definition and responsibility, and set forth an easy path for execution. Hospital command personnel adapted their usual roles and performed functions and assignments as needed. Many HICS staff had direct face-to-face contact with frontline providers in the ED and other vital areas. This was possible because of the close proximity of the hospital command headquarters to the ED. The need for additional resources was rapidly identified, and the hospital command leaders assumed direct responsibility for procuring them instead of delegating. A great example of this was when Orlando Health’s chief executive officer and chief operating officer went to our nearby hospitals to gather additional chest tubes after learning that we were running in short supply. Their main responsibilities lay ahead of them, and they were willing to help in any manner they could at the time. Some of the medical personnel were able to switch roles and pitch in to treat the second wave of victims that arrived at around 5:00 am.

As the flow of victims to the ED subsided and order began to be restored, HICS shifted gears and took on a much broader role: coordinating activities with multiple agencies, including local law enforcement, the Federal Bureau of Investigation, news media, and an array of patient and family services. Again, the timing of this tragic event allowed the needs and functions of our hospital command to concentrate the focus in a more structured manner than might have been possible during regular operational hours.

Lessons Learned and Recommendations

As with any MCI, it is important to perform after-incident debriefings to reflect upon the prehospital, ED, and hospital care to assess for areas in need of improvement. Obviously, depending on the number and type of patients who are received and the resources available at the institution, such events can stress EDs that are already at or above their capacity. At the time of this writing (less than 2 months after the incident), although we are still in the early stages of our post-incident debriefing process, we offer the following suggestions and recommendations that we believe will be a benefit to other institutions faced with similar challenges.

Dedicated Disaster Preparedness Program

Depending on the size of the institution and whether or not it is a trauma-receiving center, it is vitally important to have a team of individuals dedicated to the development and maintenance of a disaster readiness program. Eric Alberts, manager of Emergency Preparedness at Orlando Heath, emphasized the need to harness and leverage preparedness efforts and relationships with community partners, law enforcement, and EMS. In addition, he noted that these trained individuals can provide education and coordination for mass-casualty drills, assist in developing and maintaining policies and protocols, and coordinate with hospital incident command during actual events.

Practice, Practice, Practice

In order for medical staff, nursing staff, and support personnel to understand their roles and responsibilities if an MCI occurs, they must practice simulated drills. Tabletop and full-scale emergency intake drills, with a range of scenarios occurring at different times of the day and night, will improve teamwork and coordination. At least once a year, a large, full-scale community exercise that involves scene casualty collection points, law enforcement and EMS involvement, multiple EDs, and hospital-wide integration will educate staff members on their duties. There should be enough patients in these drills to stress the entire system—both ED and in-hospital. Physician involvement in these exercises is crucial. In March 2016, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter impersonating a patient brought to the ED. We feel this recent exercise, and others like it, were helpful in managing our actual mass casualty event.

Notification

When the shootings at the Pulse nightclub started, we were advised that there might be as many as 20 victims, but over the next few hours, we received more than twice as many injured patients. In any scenario where it is felt additional ED resources and personnel are needed, it is advantageous to begin the notification process as early as possible. Ideally, there are redundant methods in place to notify in-house and off-duty personnel, preferably in a multilayered system of electronic and voice communications that provides feedback as to staff availability. During daytime hours, it is easier for off-duty staff to learn of an event through news and social media. However, during early morning hours, such as when these shootings occurred, it may be difficult to notify sleeping staff that they are needed. With the trend of using mobile devices instead of landline phones, and with the ability to silence those devices during nighttime sleep hours, it has become increasingly difficult to “break through” the silence. In our event, group e-mail notifications were activated, but individual phone calls were also required. Initially, some calls to staff went to voice mail rather than being
answered directly.

Communication

Communication is an area of opportunity for improvement in almost any mass-casualty event. Redundant methods of electronic, voice, telephone, and radio communications are crucial for personnel to coordinate efforts. It is imperative that HICS and ED personnel receive updates about events on the scene and the status of potential incoming patients. An infrastructure of communications is paramount for the coordination that is needed between prehospital, ED, and in-house resources.

Throughput

Facilitating ED and hospital throughput and improving operational efficiencies are regular topics of discussion in most busy EDs. However, when it becomes necessary to intake large numbers of patients in an ED within a short period of time, the need to move patients out of the department intensifies. In many cases, to continue intake of patients, it will be necessary to quickly find areas outside of the ED—such as operating rooms, ICUs, and general floors—to transport patients to. At our facility, we normally have two operating rooms staffed throughout the night for traumas. On the night of the shootings, a total of six operating rooms were activated quickly to manage the penetrating injuries of these patients. Previously admitted medical patients were retrieved by in-house nursing staff to free up ED beds.

Media

It is important to recognize the intense social, print, online, and television media exposure that will occur with such tragedies, and have personnel and systems in place to manage it. The Pulse nightclub is located only a few short blocks south of ORMC, and the majority of all injured patients, including those with the most severe injuries, presented to our facility. As a result, the intense media coverage at our hospital physically overlapped the intense media coverage at the scene. Nearby businesses were shut down, access to several main thoroughfare roads were blocked, and some individuals mistakenly thought the hospital was closed. Our media relations department felt the most efficient way to manage information dissemination was to hold a “presser”—a press conference with a few of the health professionals involved in the care of the patients. The press conference helped to relieve some of the media presence and pressure, and provided welcomed transparency to the community.

Expect the Unexpected

Even when physicians and staff conduct regular training exercises and are familiar with policies and procedures, the controlled chaos that is typical of a true mass-casualty event will likely result in some unexpected occurrences. After injured patients began arriving at our ED, during a period when patient influx and medical care was intense, there was a brief time when we were concerned an active shooter was also in our ED. Since the mass shootings were only a few blocks from the ED, and we did not know the scope or number of shooters, it was a reasonable assumption that a perpetrator could present to the ED as a patient or active shooter. During an event such as this, it is the practice at ORMC to have security officers place the facility on lockdown; however; the added concern that an active shooter was physically present in the ED required additional law enforcement officers to methodically search the entire facility until the threat of a shooter was eliminated. Although this did not directly impact patient care, it did create another level of complexity and stress to the already challenging situation.

Emotional Impact

One should not underestimate the emotional impact of a mass-casualty event. Emergency physicians and personnel are well equipped to manage illness, injury, and death. However, an event of this magnitude, with the number and manner of injuries and deaths that presented to our ED, along with the closeness to a scene of bloodshed where many young lives were taken in a senseless act of violence, will likely have a lasting impression on many staff members. Any institution encountering such an event should have behavioral health and support counselors readily available as soon as possible.

Conclusion

When patients present in truckloads, as they did in our ambulance bay in the early hours of June 12, an ED may be inundated with injured patients without notice or preparation. Teams need to trust their instincts, their training, and one another. It is unlikely that your normal ED practice patterns will be sufficient to take care of a large surge of patients, and you will need to turn to your ingenuity, creativity, and resourcefulness to do what you think is best to save the lives of as many patients as possible. As Sarah Duran, BSN, the trauma nurse who was working as the ED charge nurse the night of the shootings, stated, “I don’t think anyone can fully prepare for anything on the scale of what happened in Orlando, but with a good foundation of protocols in place, strong set of staff, constant vigilance, and great teamwork, any hospital can be successful in handling a mass casualty incident.”

Orlando Regional Medical Center (ORMC) is an urban, academic, Level 1 trauma center with an ED that treats in excess of 85,000 patients each year. There are more than 4,500 annual trauma admissions, including penetrating and blunt mechanism injuries. We have a 3-year emergency medicine (EM) residency program, originally established in 1986, that now has 14 residents per year. The events that we experienced on the early morning of June 12, 2016 were tragic and unexpected and tested our community, our teams, and our organization. The following is a description of activity perspectives, personal reflections and feelings, and important lessons learned from which other EDs may benefit.

Prehospital/Rescue Period

The prehospital approach to a mass-casualty incident (MCI) caused by gunfire has changed significantly over the last decade, with lessons gleaned from the experience of military and domestic attacks. The Orange County (Florida) Emergency Medical Services (EMS) System, including the agencies involved in the response to the June 12, 2016 Pulse nightclub shooting incident (Orlando Fire Department, Rural Metro Ambulance, and Orange County Fire Rescue), have trained specifically on the evolving priorities during an active shooter incident. This includes targeted hemorrhage control, swift extrication, minimal interventions, and immediate transport to the appropriate receiving center. In June 2015, 1 year prior to the Pulse nightclub shooting, a protocol variance was written by medical directors, explaining that “EMS providers may engage in initial patient care with only the supplies deemed absolutely necessary for rapid evaluation and removal into a safe triage zone.” This variance applies when there is an active shooter scenario. In addition, in 2014, 2015, and 2016, we conducted large scale, multiagency community exercises, encompassing shooting/active shooter scenarios and drills.

On June 12, 2016, EMS units were on scene of the Pulse nightclub in downtown Orlando less than 5 minutes after shooting began. It became immediately obvious that additional resources would be necessary. Soon after the incident, an MCI alert was activated from the Orlando Fire Department Communications Center, utilizing a software system to notify area hospitals and the medical directors that up to 20 patients had been shot, and requesting status on bed availability. Christopher L. Hunter, MD, PhD, one of our associate EMS medical directors, was working in the ED at a hospital several miles away from the incident and began coordinating efforts to distribute patients to the appropriate destination via radio and phone communication between the scene, the communications center, and the trauma center.

On scene, a group of law enforcement officers were engaging the shooter while others assisted in extracting victims from the club and surrounding area. Injured victims were brought to a casualty collection point, under cover, across the street and were transported as units became available. Initially, law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload. Per previous training, minimal interventions were performed, and unlike standard procedure, EMS could offer no prearrival report to the hospital. The decision was made to triage only patients meeting Florida’s state trauma alert criteria to ORMC, and funnel other patients to nearby nontrauma centers. Dr Hunter attempted to notify the hospitals of patients as they were transported off the scene; however, the extremely short transport times made this process difficult.

Over the course of the incident, on-scene commands designated a casualty collection point, a transport unit staging area, and a hospital liaison. Emergency medical service responders cooperated with law enforcement to transport injured patients throughout the response. By the end of the event, nearly 100 EMS providers utilizing dozens of vehicles had responded to the scene.

The ED Period

The overnight shift of Saturday, June 11 was slower than usual in the ORMC ED, and triage housed the typical Saturday-night complaints. One of our mid-level providers, Brian Clayton, ARNP, worked in the fast track pod treating lower acuity illnesses, while the four senior residents discussed who might receive the honor of leaving early. Even the senior attending, Gary A. Parrish, MD, wrapped up his patients and was ready to leave right on time. The 11:00 pm to 7:00 am attending, Kathryn  J. Bondani, MD, was looking forward to an easy shift with four graduating senior residents. We had just called in an order from a popular nearby sandwich shop when suddenly, a slew of police cars flew past the hospital—not unusual given our proximity to downtown. The radio squawked “Multiple gunshots wounds en route.” Someone said “a club downtown got shot up.” In anticipation of multiple patient arrivals, resident Amanda M. Stone, MD, and the attending hurried to the trauma/ressuscitation bay. Another resident, Amanda F. Tarkowski, MD, called the trauma attending to rally his team downstairs, informing him that “A club downtown has a shooter and we have multiple patients with a 2-minute ETA.” Multiple gunshot wounds (GSWs) at once is not unusual for our Level 1 trauma center.

The first patient arrived shortly after 2:00 am and had multiple GSWs to the abdomen, but was awake and talking. He was mildly tachycardic, but his blood pressure (BP) was stable. We all gaped at the fist-sized wound on his back—some of us had never seen a GSW like this before. It was apparent that he needed to go to the operating room, but before preparations could be made, three more patients rolled into the ED. Instead of our usual organized, methodical EMS report, these patients were dropped off by a police pickup truck and rolled in on our own stretchers by nurses and technicians. Soon, all six of our trauma bays were filled with critical patients. Christopher H. Ponder, MD, recalled, “I heard an overhead page for ‘all available trauma nurses to the trauma bay’ shortly followed by a more concerned-sounding ‘all available staff to the trauma bay.’” All four senior EM residents, both EM attendings, the trauma attending, four trauma residents, multiple ED nurses, technicians, and various ancillary staff quickly descended on the patients. Chest tubes were placed, and multiple patients were intubated. Several thoracotomies were performed at the initial point when the team was unaware of the exact number of patients who would ultimately follow. Blood bags were hung and tranexamic acid was administered liberally. Unfortunately, some of these initial attempts were unsuccessful, as the first wave contained the most critically injured patients.

We barely had time to reflect on the dead as more patients filled the hallways. In the midst of all of this, triage decisions came quickly—awake and talking patients with an acceptable BP were moved out of the trauma bay in favor of less stable patients. Intubation and chest-tube placement decisions were made instantly. There was no time for routine X-rays or laboratory evaluation. Nurses, technicians, and doctors crowded the trauma bay desperately trying to stabilize the critically injured. Vital signs were taken manually. Dr Ponder called his colleague Thomas N. Smith, MD, who was also a graduating senior EM resident, and who happened to be staffing the children’s ED across the street that night. “Is there any way you can make it over here right now?” he shouted into the phone. Dr Smith quickly grabbed several trauma supplies and hitched a ride with security to the ORMC ED to assist. He was confronted with the scene of the previously mentioned “first wave” and grabbed an ultrasound machine to help triage these unfortunate patients. In addition to Dr Smith, unit clerks continued making calls to additional off-duty medical, nursing, and support staff. Critical care attendings and fellows responded from upstairs to assist in the ED. The Hospital Incident Command System (HICS) was initiated to provide hospital and corporate coordination of services. Timothy B. Bullard, MD, another EM attending physician and medical staff director of HICS, was en route to the ED to assist in the response.

Amidst the overwhelming mass of mortally and critically wounded patients, we were told stories of terror from just down the road. The sense of horror was almost contagious, and we all wondered if the violence would spread to the hospital.

About an hour into the ordeal, we heard another page overhead “Code Silver, ED Triage. Code Silver, ED Triage.” Everyone in the trauma bay froze. We heard someone shout from the hallway “Shots fired in triage!” After a few seconds, those nearest the trauma bay doors pushed them shut. One of the trauma surgeons shouted, “Keep caring for your patients, push the portable X-ray machines in front of the doors.” That is exactly what happened, and we worked in the barricaded trauma room for the longest few minutes of the night. We would later learn that this report was false, but fearing for our own lives as well as the lives of our patients is an experience that few, if any, of us had previously been through. The fact that we continued to work in such a situation illustrates everyone’s dedication to their patients and mission.

After the first wave of patients, it was clear that reassessing patients was now our greatest challenge. There were multiple patients with stable vital signs but who had GSWs to the abdomen, pelvis, and thorax and required surgery. Having realized that the ultrasound machine and focused assessment with sonography for trauma (FAST) examinations were the most practical rapid imaging modality, Drs Tarkowski, Ponder, and Smith grabbed the machine and went from room to room repeating the FAST examinations, vital signs, and assessments for missed wounds. A portable computer allowed us to order X-ray orders for patients with extremity wounds. Several patients who initially had negative FASTs had a repeat examination that was positive for free fluid. The operating room triage list shuffled based on these examinations.

At this point, there seemed to be a never-ending list of “Doe” names on the electronic medical record (EMR) tracking board. Tracking the location of patients was a dynamic process, and updating the tracking board was difficult. Patients were continually cycled in and out of the trauma bay, shuffled in and out of treatment rooms, lined up in the hallways, and transported up to the intensive care unit (ICU). Some of those “Doe” names belonged to patients who had succumbed to their injuries. Some patients had empty, bloody charts next to them on their stretcher. Every patient had a wristband. Dr Tarkowski improvised a rapid documentation system using quarter sheets of scrap paper that were taped either to the stretcher or door with a patient name, brief list of injuries, FAST examination result, pending tests, and medications given. This system was an efficient way of identifying which patients had been evaluated, what had been done, and what was pending.

While we were “rounding” on our patients, down the street, law enforcement had broken down the club’s wall, and a second wave of patients began to arrive. Two residents completed the secondary evaluations while the other three resuscitated new patients. The second wave seemed like a repeat of the first. Several extremity-only injuries were triaged directly to the hallways to be seen by the two residents outside of the trauma bay. By this time, the orthopedic surgery service had come down to the ED and was washing out wounds, splinting, and making plans for surgery. The internal medicine service and the medical critical care team were helping reassess patients as well.

There were many emotional moments. Dr Ponder remembered, “One of the first few patients I saw was pulseless, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’ That’s when I realized the gravity of our situation. For almost 2 hours, each resident cycled through patients.” Dr Stone recounted, “I just went down the line of patients, from head of the bed to head of the bed, some patients still on EMS stretchers, intubating many of them. It was surreal to see that many severely injured in one place.” Tory L. Weatherford, MD, recalled, “It was controlled chaos. My training kicked in, and it became about just trying to do anything possible to help.”

Dr Bondani, the overnight attending, said she does not remember many specifics from the event. “Faces and injuries blurred together. I remember looking in one young man’s eyes and telling him, ‘We are going to help you, just hang in there,’ and telling another panicking woman, ‘You’re talking, you can feel pain, you’re alive. Calm down.’ It was organized chaos as we swept from patient to patient moving as quickly as possible. Your training kicks in and you do what needs to be done in the moment.”

We were fortunate to have the EM team we did, and to be in the place that we were. On duty, we had five senior graduating residents, essentially with attending-level skills and training, who had been together since day one. “We gave everything we had; there was no time to stop. We went where our hands could be helpful—it didn’t matter if it was your traditional role or not,” said Dr Weatherford.

Dr Tarkowski remembered what it was like leaving the walls of the ED later that morning. “Leaving the hospital didn’t feel like a success. We knew the work we did was good, that we did everything we could, but it didn’t feel like it. It felt heavy. It felt empty.” Afterward, the emotional toll set in. We gathered up the names of the deceased and looked at a status board littered with “Doe” names, and we tried hard not to break down at the violence and the pain we witnessed.

Immediate Recovery Period (Prehospital Setting)

In the aftermath of the initial rescue operation, stabilization of injured victims, and demobilization of resources, a second “event” unfolded—hundreds of family members flooded to ORMC looking for unaccounted loved ones. At this point, there were dozens of deceased and critically injured patients who remained unidentified, and addressing the needs of both the victims and the families was becoming overwhelming. With the cooperation of federal, state, county, city, and private resources, a family reunification center (FRC; a family staging area/family reception center) was created and managed initially within the hospital. At this site, grief counselors, victim advocates, law enforcement and medical examiner’s officials, hospital chaplains, and translators gathered with the loved ones of those missing to synchronize efforts to identify and reunite them. The Emergency Operations Center quickly created a telephone hotline and Web site to guide those in need to this resource. Food and housing for those in need were provided by the generosity of our community—which cannot be overstated in the wake of this tragedy. As days passed, the FRC transitioned to a new location as the Orlando United Assistance Center, and will continue to serve as a navigation point for those who are and will be affected by the event for months to come.

Hospital Incident Command System

The HICS was activated shortly past 3:00 am, just after the initial wave of victims flooded our ED and the gravity of the situation became apparent. The ED and trauma services were already near full staff due to timing, rapid response, and communication between the traumatologists, as well as a bit of luck. Because of the time of the disaster, our normal notification process for incident command and all personnel was severely limited. In retrospect, this turned out to be a blessing. While everyone who normally would respond to HICS was not available, individuals serving in key positions were reached by personal phone calls and were on-site quickly. One of the main functions of HICS is to control the internal chaos that arises when a disaster occurs and all personnel want to assist in some manner. We have spent hours during drills crafting communications that target key personnel necessary to meet the mission, while controlling well-intentioned but unnecessary personnel. In our drills, this is not an issue because everyone knows the exercise is not reality; however, in a real disaster, everyone wants to help. This was confirmed by the guilt that so many of our team members expressed at not being involved that Sunday.

With an initial skeleton crew in incident command, it was easy to focus on the immediate needs of patient care. The strong leadership and cool heads of our incident command leadership led to rapid role definition and responsibility, and set forth an easy path for execution. Hospital command personnel adapted their usual roles and performed functions and assignments as needed. Many HICS staff had direct face-to-face contact with frontline providers in the ED and other vital areas. This was possible because of the close proximity of the hospital command headquarters to the ED. The need for additional resources was rapidly identified, and the hospital command leaders assumed direct responsibility for procuring them instead of delegating. A great example of this was when Orlando Health’s chief executive officer and chief operating officer went to our nearby hospitals to gather additional chest tubes after learning that we were running in short supply. Their main responsibilities lay ahead of them, and they were willing to help in any manner they could at the time. Some of the medical personnel were able to switch roles and pitch in to treat the second wave of victims that arrived at around 5:00 am.

As the flow of victims to the ED subsided and order began to be restored, HICS shifted gears and took on a much broader role: coordinating activities with multiple agencies, including local law enforcement, the Federal Bureau of Investigation, news media, and an array of patient and family services. Again, the timing of this tragic event allowed the needs and functions of our hospital command to concentrate the focus in a more structured manner than might have been possible during regular operational hours.

Lessons Learned and Recommendations

As with any MCI, it is important to perform after-incident debriefings to reflect upon the prehospital, ED, and hospital care to assess for areas in need of improvement. Obviously, depending on the number and type of patients who are received and the resources available at the institution, such events can stress EDs that are already at or above their capacity. At the time of this writing (less than 2 months after the incident), although we are still in the early stages of our post-incident debriefing process, we offer the following suggestions and recommendations that we believe will be a benefit to other institutions faced with similar challenges.

Dedicated Disaster Preparedness Program

Depending on the size of the institution and whether or not it is a trauma-receiving center, it is vitally important to have a team of individuals dedicated to the development and maintenance of a disaster readiness program. Eric Alberts, manager of Emergency Preparedness at Orlando Heath, emphasized the need to harness and leverage preparedness efforts and relationships with community partners, law enforcement, and EMS. In addition, he noted that these trained individuals can provide education and coordination for mass-casualty drills, assist in developing and maintaining policies and protocols, and coordinate with hospital incident command during actual events.

Practice, Practice, Practice

In order for medical staff, nursing staff, and support personnel to understand their roles and responsibilities if an MCI occurs, they must practice simulated drills. Tabletop and full-scale emergency intake drills, with a range of scenarios occurring at different times of the day and night, will improve teamwork and coordination. At least once a year, a large, full-scale community exercise that involves scene casualty collection points, law enforcement and EMS involvement, multiple EDs, and hospital-wide integration will educate staff members on their duties. There should be enough patients in these drills to stress the entire system—both ED and in-hospital. Physician involvement in these exercises is crucial. In March 2016, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter impersonating a patient brought to the ED. We feel this recent exercise, and others like it, were helpful in managing our actual mass casualty event.

Notification

When the shootings at the Pulse nightclub started, we were advised that there might be as many as 20 victims, but over the next few hours, we received more than twice as many injured patients. In any scenario where it is felt additional ED resources and personnel are needed, it is advantageous to begin the notification process as early as possible. Ideally, there are redundant methods in place to notify in-house and off-duty personnel, preferably in a multilayered system of electronic and voice communications that provides feedback as to staff availability. During daytime hours, it is easier for off-duty staff to learn of an event through news and social media. However, during early morning hours, such as when these shootings occurred, it may be difficult to notify sleeping staff that they are needed. With the trend of using mobile devices instead of landline phones, and with the ability to silence those devices during nighttime sleep hours, it has become increasingly difficult to “break through” the silence. In our event, group e-mail notifications were activated, but individual phone calls were also required. Initially, some calls to staff went to voice mail rather than being
answered directly.

Communication

Communication is an area of opportunity for improvement in almost any mass-casualty event. Redundant methods of electronic, voice, telephone, and radio communications are crucial for personnel to coordinate efforts. It is imperative that HICS and ED personnel receive updates about events on the scene and the status of potential incoming patients. An infrastructure of communications is paramount for the coordination that is needed between prehospital, ED, and in-house resources.

Throughput

Facilitating ED and hospital throughput and improving operational efficiencies are regular topics of discussion in most busy EDs. However, when it becomes necessary to intake large numbers of patients in an ED within a short period of time, the need to move patients out of the department intensifies. In many cases, to continue intake of patients, it will be necessary to quickly find areas outside of the ED—such as operating rooms, ICUs, and general floors—to transport patients to. At our facility, we normally have two operating rooms staffed throughout the night for traumas. On the night of the shootings, a total of six operating rooms were activated quickly to manage the penetrating injuries of these patients. Previously admitted medical patients were retrieved by in-house nursing staff to free up ED beds.

Media

It is important to recognize the intense social, print, online, and television media exposure that will occur with such tragedies, and have personnel and systems in place to manage it. The Pulse nightclub is located only a few short blocks south of ORMC, and the majority of all injured patients, including those with the most severe injuries, presented to our facility. As a result, the intense media coverage at our hospital physically overlapped the intense media coverage at the scene. Nearby businesses were shut down, access to several main thoroughfare roads were blocked, and some individuals mistakenly thought the hospital was closed. Our media relations department felt the most efficient way to manage information dissemination was to hold a “presser”—a press conference with a few of the health professionals involved in the care of the patients. The press conference helped to relieve some of the media presence and pressure, and provided welcomed transparency to the community.

Expect the Unexpected

Even when physicians and staff conduct regular training exercises and are familiar with policies and procedures, the controlled chaos that is typical of a true mass-casualty event will likely result in some unexpected occurrences. After injured patients began arriving at our ED, during a period when patient influx and medical care was intense, there was a brief time when we were concerned an active shooter was also in our ED. Since the mass shootings were only a few blocks from the ED, and we did not know the scope or number of shooters, it was a reasonable assumption that a perpetrator could present to the ED as a patient or active shooter. During an event such as this, it is the practice at ORMC to have security officers place the facility on lockdown; however; the added concern that an active shooter was physically present in the ED required additional law enforcement officers to methodically search the entire facility until the threat of a shooter was eliminated. Although this did not directly impact patient care, it did create another level of complexity and stress to the already challenging situation.

Emotional Impact

One should not underestimate the emotional impact of a mass-casualty event. Emergency physicians and personnel are well equipped to manage illness, injury, and death. However, an event of this magnitude, with the number and manner of injuries and deaths that presented to our ED, along with the closeness to a scene of bloodshed where many young lives were taken in a senseless act of violence, will likely have a lasting impression on many staff members. Any institution encountering such an event should have behavioral health and support counselors readily available as soon as possible.

Conclusion

When patients present in truckloads, as they did in our ambulance bay in the early hours of June 12, an ED may be inundated with injured patients without notice or preparation. Teams need to trust their instincts, their training, and one another. It is unlikely that your normal ED practice patterns will be sufficient to take care of a large surge of patients, and you will need to turn to your ingenuity, creativity, and resourcefulness to do what you think is best to save the lives of as many patients as possible. As Sarah Duran, BSN, the trauma nurse who was working as the ED charge nurse the night of the shootings, stated, “I don’t think anyone can fully prepare for anything on the scale of what happened in Orlando, but with a good foundation of protocols in place, strong set of staff, constant vigilance, and great teamwork, any hospital can be successful in handling a mass casualty incident.”

Orlando Regional Medical Center (ORMC) is an urban, academic, Level 1 trauma center with an ED that treats in excess of 85,000 patients each year. There are more than 4,500 annual trauma admissions, including penetrating and blunt mechanism injuries. We have a 3-year emergency medicine (EM) residency program, originally established in 1986, that now has 14 residents per year. The events that we experienced on the early morning of June 12, 2016 were tragic and unexpected and tested our community, our teams, and our organization. The following is a description of activity perspectives, personal reflections and feelings, and important lessons learned from which other EDs may benefit.

Prehospital/Rescue Period

The prehospital approach to a mass-casualty incident (MCI) caused by gunfire has changed significantly over the last decade, with lessons gleaned from the experience of military and domestic attacks. The Orange County (Florida) Emergency Medical Services (EMS) System, including the agencies involved in the response to the June 12, 2016 Pulse nightclub shooting incident (Orlando Fire Department, Rural Metro Ambulance, and Orange County Fire Rescue), have trained specifically on the evolving priorities during an active shooter incident. This includes targeted hemorrhage control, swift extrication, minimal interventions, and immediate transport to the appropriate receiving center. In June 2015, 1 year prior to the Pulse nightclub shooting, a protocol variance was written by medical directors, explaining that “EMS providers may engage in initial patient care with only the supplies deemed absolutely necessary for rapid evaluation and removal into a safe triage zone.” This variance applies when there is an active shooter scenario. In addition, in 2014, 2015, and 2016, we conducted large scale, multiagency community exercises, encompassing shooting/active shooter scenarios and drills.

On June 12, 2016, EMS units were on scene of the Pulse nightclub in downtown Orlando less than 5 minutes after shooting began. It became immediately obvious that additional resources would be necessary. Soon after the incident, an MCI alert was activated from the Orlando Fire Department Communications Center, utilizing a software system to notify area hospitals and the medical directors that up to 20 patients had been shot, and requesting status on bed availability. Christopher L. Hunter, MD, PhD, one of our associate EMS medical directors, was working in the ED at a hospital several miles away from the incident and began coordinating efforts to distribute patients to the appropriate destination via radio and phone communication between the scene, the communications center, and the trauma center.

On scene, a group of law enforcement officers were engaging the shooter while others assisted in extracting victims from the club and surrounding area. Injured victims were brought to a casualty collection point, under cover, across the street and were transported as units became available. Initially, law enforcement vehicles and ambulances would make the two-block drive from the scene to ORMC carrying as many patients as they safely could, and return immediately after offload. Per previous training, minimal interventions were performed, and unlike standard procedure, EMS could offer no prearrival report to the hospital. The decision was made to triage only patients meeting Florida’s state trauma alert criteria to ORMC, and funnel other patients to nearby nontrauma centers. Dr Hunter attempted to notify the hospitals of patients as they were transported off the scene; however, the extremely short transport times made this process difficult.

Over the course of the incident, on-scene commands designated a casualty collection point, a transport unit staging area, and a hospital liaison. Emergency medical service responders cooperated with law enforcement to transport injured patients throughout the response. By the end of the event, nearly 100 EMS providers utilizing dozens of vehicles had responded to the scene.

The ED Period

The overnight shift of Saturday, June 11 was slower than usual in the ORMC ED, and triage housed the typical Saturday-night complaints. One of our mid-level providers, Brian Clayton, ARNP, worked in the fast track pod treating lower acuity illnesses, while the four senior residents discussed who might receive the honor of leaving early. Even the senior attending, Gary A. Parrish, MD, wrapped up his patients and was ready to leave right on time. The 11:00 pm to 7:00 am attending, Kathryn  J. Bondani, MD, was looking forward to an easy shift with four graduating senior residents. We had just called in an order from a popular nearby sandwich shop when suddenly, a slew of police cars flew past the hospital—not unusual given our proximity to downtown. The radio squawked “Multiple gunshots wounds en route.” Someone said “a club downtown got shot up.” In anticipation of multiple patient arrivals, resident Amanda M. Stone, MD, and the attending hurried to the trauma/ressuscitation bay. Another resident, Amanda F. Tarkowski, MD, called the trauma attending to rally his team downstairs, informing him that “A club downtown has a shooter and we have multiple patients with a 2-minute ETA.” Multiple gunshot wounds (GSWs) at once is not unusual for our Level 1 trauma center.

The first patient arrived shortly after 2:00 am and had multiple GSWs to the abdomen, but was awake and talking. He was mildly tachycardic, but his blood pressure (BP) was stable. We all gaped at the fist-sized wound on his back—some of us had never seen a GSW like this before. It was apparent that he needed to go to the operating room, but before preparations could be made, three more patients rolled into the ED. Instead of our usual organized, methodical EMS report, these patients were dropped off by a police pickup truck and rolled in on our own stretchers by nurses and technicians. Soon, all six of our trauma bays were filled with critical patients. Christopher H. Ponder, MD, recalled, “I heard an overhead page for ‘all available trauma nurses to the trauma bay’ shortly followed by a more concerned-sounding ‘all available staff to the trauma bay.’” All four senior EM residents, both EM attendings, the trauma attending, four trauma residents, multiple ED nurses, technicians, and various ancillary staff quickly descended on the patients. Chest tubes were placed, and multiple patients were intubated. Several thoracotomies were performed at the initial point when the team was unaware of the exact number of patients who would ultimately follow. Blood bags were hung and tranexamic acid was administered liberally. Unfortunately, some of these initial attempts were unsuccessful, as the first wave contained the most critically injured patients.

We barely had time to reflect on the dead as more patients filled the hallways. In the midst of all of this, triage decisions came quickly—awake and talking patients with an acceptable BP were moved out of the trauma bay in favor of less stable patients. Intubation and chest-tube placement decisions were made instantly. There was no time for routine X-rays or laboratory evaluation. Nurses, technicians, and doctors crowded the trauma bay desperately trying to stabilize the critically injured. Vital signs were taken manually. Dr Ponder called his colleague Thomas N. Smith, MD, who was also a graduating senior EM resident, and who happened to be staffing the children’s ED across the street that night. “Is there any way you can make it over here right now?” he shouted into the phone. Dr Smith quickly grabbed several trauma supplies and hitched a ride with security to the ORMC ED to assist. He was confronted with the scene of the previously mentioned “first wave” and grabbed an ultrasound machine to help triage these unfortunate patients. In addition to Dr Smith, unit clerks continued making calls to additional off-duty medical, nursing, and support staff. Critical care attendings and fellows responded from upstairs to assist in the ED. The Hospital Incident Command System (HICS) was initiated to provide hospital and corporate coordination of services. Timothy B. Bullard, MD, another EM attending physician and medical staff director of HICS, was en route to the ED to assist in the response.

Amidst the overwhelming mass of mortally and critically wounded patients, we were told stories of terror from just down the road. The sense of horror was almost contagious, and we all wondered if the violence would spread to the hospital.

About an hour into the ordeal, we heard another page overhead “Code Silver, ED Triage. Code Silver, ED Triage.” Everyone in the trauma bay froze. We heard someone shout from the hallway “Shots fired in triage!” After a few seconds, those nearest the trauma bay doors pushed them shut. One of the trauma surgeons shouted, “Keep caring for your patients, push the portable X-ray machines in front of the doors.” That is exactly what happened, and we worked in the barricaded trauma room for the longest few minutes of the night. We would later learn that this report was false, but fearing for our own lives as well as the lives of our patients is an experience that few, if any, of us had previously been through. The fact that we continued to work in such a situation illustrates everyone’s dedication to their patients and mission.

After the first wave of patients, it was clear that reassessing patients was now our greatest challenge. There were multiple patients with stable vital signs but who had GSWs to the abdomen, pelvis, and thorax and required surgery. Having realized that the ultrasound machine and focused assessment with sonography for trauma (FAST) examinations were the most practical rapid imaging modality, Drs Tarkowski, Ponder, and Smith grabbed the machine and went from room to room repeating the FAST examinations, vital signs, and assessments for missed wounds. A portable computer allowed us to order X-ray orders for patients with extremity wounds. Several patients who initially had negative FASTs had a repeat examination that was positive for free fluid. The operating room triage list shuffled based on these examinations.

At this point, there seemed to be a never-ending list of “Doe” names on the electronic medical record (EMR) tracking board. Tracking the location of patients was a dynamic process, and updating the tracking board was difficult. Patients were continually cycled in and out of the trauma bay, shuffled in and out of treatment rooms, lined up in the hallways, and transported up to the intensive care unit (ICU). Some of those “Doe” names belonged to patients who had succumbed to their injuries. Some patients had empty, bloody charts next to them on their stretcher. Every patient had a wristband. Dr Tarkowski improvised a rapid documentation system using quarter sheets of scrap paper that were taped either to the stretcher or door with a patient name, brief list of injuries, FAST examination result, pending tests, and medications given. This system was an efficient way of identifying which patients had been evaluated, what had been done, and what was pending.

While we were “rounding” on our patients, down the street, law enforcement had broken down the club’s wall, and a second wave of patients began to arrive. Two residents completed the secondary evaluations while the other three resuscitated new patients. The second wave seemed like a repeat of the first. Several extremity-only injuries were triaged directly to the hallways to be seen by the two residents outside of the trauma bay. By this time, the orthopedic surgery service had come down to the ED and was washing out wounds, splinting, and making plans for surgery. The internal medicine service and the medical critical care team were helping reassess patients as well.

There were many emotional moments. Dr Ponder remembered, “One of the first few patients I saw was pulseless, and as I went to start chest compressions, I was stopped by a trauma surgeon who said, ‘He’s gone, focus on the ones we can help.’ That’s when I realized the gravity of our situation. For almost 2 hours, each resident cycled through patients.” Dr Stone recounted, “I just went down the line of patients, from head of the bed to head of the bed, some patients still on EMS stretchers, intubating many of them. It was surreal to see that many severely injured in one place.” Tory L. Weatherford, MD, recalled, “It was controlled chaos. My training kicked in, and it became about just trying to do anything possible to help.”

Dr Bondani, the overnight attending, said she does not remember many specifics from the event. “Faces and injuries blurred together. I remember looking in one young man’s eyes and telling him, ‘We are going to help you, just hang in there,’ and telling another panicking woman, ‘You’re talking, you can feel pain, you’re alive. Calm down.’ It was organized chaos as we swept from patient to patient moving as quickly as possible. Your training kicks in and you do what needs to be done in the moment.”

We were fortunate to have the EM team we did, and to be in the place that we were. On duty, we had five senior graduating residents, essentially with attending-level skills and training, who had been together since day one. “We gave everything we had; there was no time to stop. We went where our hands could be helpful—it didn’t matter if it was your traditional role or not,” said Dr Weatherford.

Dr Tarkowski remembered what it was like leaving the walls of the ED later that morning. “Leaving the hospital didn’t feel like a success. We knew the work we did was good, that we did everything we could, but it didn’t feel like it. It felt heavy. It felt empty.” Afterward, the emotional toll set in. We gathered up the names of the deceased and looked at a status board littered with “Doe” names, and we tried hard not to break down at the violence and the pain we witnessed.

Immediate Recovery Period (Prehospital Setting)

In the aftermath of the initial rescue operation, stabilization of injured victims, and demobilization of resources, a second “event” unfolded—hundreds of family members flooded to ORMC looking for unaccounted loved ones. At this point, there were dozens of deceased and critically injured patients who remained unidentified, and addressing the needs of both the victims and the families was becoming overwhelming. With the cooperation of federal, state, county, city, and private resources, a family reunification center (FRC; a family staging area/family reception center) was created and managed initially within the hospital. At this site, grief counselors, victim advocates, law enforcement and medical examiner’s officials, hospital chaplains, and translators gathered with the loved ones of those missing to synchronize efforts to identify and reunite them. The Emergency Operations Center quickly created a telephone hotline and Web site to guide those in need to this resource. Food and housing for those in need were provided by the generosity of our community—which cannot be overstated in the wake of this tragedy. As days passed, the FRC transitioned to a new location as the Orlando United Assistance Center, and will continue to serve as a navigation point for those who are and will be affected by the event for months to come.

Hospital Incident Command System

The HICS was activated shortly past 3:00 am, just after the initial wave of victims flooded our ED and the gravity of the situation became apparent. The ED and trauma services were already near full staff due to timing, rapid response, and communication between the traumatologists, as well as a bit of luck. Because of the time of the disaster, our normal notification process for incident command and all personnel was severely limited. In retrospect, this turned out to be a blessing. While everyone who normally would respond to HICS was not available, individuals serving in key positions were reached by personal phone calls and were on-site quickly. One of the main functions of HICS is to control the internal chaos that arises when a disaster occurs and all personnel want to assist in some manner. We have spent hours during drills crafting communications that target key personnel necessary to meet the mission, while controlling well-intentioned but unnecessary personnel. In our drills, this is not an issue because everyone knows the exercise is not reality; however, in a real disaster, everyone wants to help. This was confirmed by the guilt that so many of our team members expressed at not being involved that Sunday.

With an initial skeleton crew in incident command, it was easy to focus on the immediate needs of patient care. The strong leadership and cool heads of our incident command leadership led to rapid role definition and responsibility, and set forth an easy path for execution. Hospital command personnel adapted their usual roles and performed functions and assignments as needed. Many HICS staff had direct face-to-face contact with frontline providers in the ED and other vital areas. This was possible because of the close proximity of the hospital command headquarters to the ED. The need for additional resources was rapidly identified, and the hospital command leaders assumed direct responsibility for procuring them instead of delegating. A great example of this was when Orlando Health’s chief executive officer and chief operating officer went to our nearby hospitals to gather additional chest tubes after learning that we were running in short supply. Their main responsibilities lay ahead of them, and they were willing to help in any manner they could at the time. Some of the medical personnel were able to switch roles and pitch in to treat the second wave of victims that arrived at around 5:00 am.

As the flow of victims to the ED subsided and order began to be restored, HICS shifted gears and took on a much broader role: coordinating activities with multiple agencies, including local law enforcement, the Federal Bureau of Investigation, news media, and an array of patient and family services. Again, the timing of this tragic event allowed the needs and functions of our hospital command to concentrate the focus in a more structured manner than might have been possible during regular operational hours.

Lessons Learned and Recommendations

As with any MCI, it is important to perform after-incident debriefings to reflect upon the prehospital, ED, and hospital care to assess for areas in need of improvement. Obviously, depending on the number and type of patients who are received and the resources available at the institution, such events can stress EDs that are already at or above their capacity. At the time of this writing (less than 2 months after the incident), although we are still in the early stages of our post-incident debriefing process, we offer the following suggestions and recommendations that we believe will be a benefit to other institutions faced with similar challenges.

Dedicated Disaster Preparedness Program

Depending on the size of the institution and whether or not it is a trauma-receiving center, it is vitally important to have a team of individuals dedicated to the development and maintenance of a disaster readiness program. Eric Alberts, manager of Emergency Preparedness at Orlando Heath, emphasized the need to harness and leverage preparedness efforts and relationships with community partners, law enforcement, and EMS. In addition, he noted that these trained individuals can provide education and coordination for mass-casualty drills, assist in developing and maintaining policies and protocols, and coordinate with hospital incident command during actual events.

Practice, Practice, Practice

In order for medical staff, nursing staff, and support personnel to understand their roles and responsibilities if an MCI occurs, they must practice simulated drills. Tabletop and full-scale emergency intake drills, with a range of scenarios occurring at different times of the day and night, will improve teamwork and coordination. At least once a year, a large, full-scale community exercise that involves scene casualty collection points, law enforcement and EMS involvement, multiple EDs, and hospital-wide integration will educate staff members on their duties. There should be enough patients in these drills to stress the entire system—both ED and in-hospital. Physician involvement in these exercises is crucial. In March 2016, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter impersonating a patient brought to the ED. We feel this recent exercise, and others like it, were helpful in managing our actual mass casualty event.

Notification

When the shootings at the Pulse nightclub started, we were advised that there might be as many as 20 victims, but over the next few hours, we received more than twice as many injured patients. In any scenario where it is felt additional ED resources and personnel are needed, it is advantageous to begin the notification process as early as possible. Ideally, there are redundant methods in place to notify in-house and off-duty personnel, preferably in a multilayered system of electronic and voice communications that provides feedback as to staff availability. During daytime hours, it is easier for off-duty staff to learn of an event through news and social media. However, during early morning hours, such as when these shootings occurred, it may be difficult to notify sleeping staff that they are needed. With the trend of using mobile devices instead of landline phones, and with the ability to silence those devices during nighttime sleep hours, it has become increasingly difficult to “break through” the silence. In our event, group e-mail notifications were activated, but individual phone calls were also required. Initially, some calls to staff went to voice mail rather than being
answered directly.

Communication

Communication is an area of opportunity for improvement in almost any mass-casualty event. Redundant methods of electronic, voice, telephone, and radio communications are crucial for personnel to coordinate efforts. It is imperative that HICS and ED personnel receive updates about events on the scene and the status of potential incoming patients. An infrastructure of communications is paramount for the coordination that is needed between prehospital, ED, and in-house resources.

Throughput

Facilitating ED and hospital throughput and improving operational efficiencies are regular topics of discussion in most busy EDs. However, when it becomes necessary to intake large numbers of patients in an ED within a short period of time, the need to move patients out of the department intensifies. In many cases, to continue intake of patients, it will be necessary to quickly find areas outside of the ED—such as operating rooms, ICUs, and general floors—to transport patients to. At our facility, we normally have two operating rooms staffed throughout the night for traumas. On the night of the shootings, a total of six operating rooms were activated quickly to manage the penetrating injuries of these patients. Previously admitted medical patients were retrieved by in-house nursing staff to free up ED beds.

Media

It is important to recognize the intense social, print, online, and television media exposure that will occur with such tragedies, and have personnel and systems in place to manage it. The Pulse nightclub is located only a few short blocks south of ORMC, and the majority of all injured patients, including those with the most severe injuries, presented to our facility. As a result, the intense media coverage at our hospital physically overlapped the intense media coverage at the scene. Nearby businesses were shut down, access to several main thoroughfare roads were blocked, and some individuals mistakenly thought the hospital was closed. Our media relations department felt the most efficient way to manage information dissemination was to hold a “presser”—a press conference with a few of the health professionals involved in the care of the patients. The press conference helped to relieve some of the media presence and pressure, and provided welcomed transparency to the community.

Expect the Unexpected

Even when physicians and staff conduct regular training exercises and are familiar with policies and procedures, the controlled chaos that is typical of a true mass-casualty event will likely result in some unexpected occurrences. After injured patients began arriving at our ED, during a period when patient influx and medical care was intense, there was a brief time when we were concerned an active shooter was also in our ED. Since the mass shootings were only a few blocks from the ED, and we did not know the scope or number of shooters, it was a reasonable assumption that a perpetrator could present to the ED as a patient or active shooter. During an event such as this, it is the practice at ORMC to have security officers place the facility on lockdown; however; the added concern that an active shooter was physically present in the ED required additional law enforcement officers to methodically search the entire facility until the threat of a shooter was eliminated. Although this did not directly impact patient care, it did create another level of complexity and stress to the already challenging situation.

Emotional Impact

One should not underestimate the emotional impact of a mass-casualty event. Emergency physicians and personnel are well equipped to manage illness, injury, and death. However, an event of this magnitude, with the number and manner of injuries and deaths that presented to our ED, along with the closeness to a scene of bloodshed where many young lives were taken in a senseless act of violence, will likely have a lasting impression on many staff members. Any institution encountering such an event should have behavioral health and support counselors readily available as soon as possible.

Conclusion

When patients present in truckloads, as they did in our ambulance bay in the early hours of June 12, an ED may be inundated with injured patients without notice or preparation. Teams need to trust their instincts, their training, and one another. It is unlikely that your normal ED practice patterns will be sufficient to take care of a large surge of patients, and you will need to turn to your ingenuity, creativity, and resourcefulness to do what you think is best to save the lives of as many patients as possible. As Sarah Duran, BSN, the trauma nurse who was working as the ED charge nurse the night of the shootings, stated, “I don’t think anyone can fully prepare for anything on the scale of what happened in Orlando, but with a good foundation of protocols in place, strong set of staff, constant vigilance, and great teamwork, any hospital can be successful in handling a mass casualty incident.”

Cosmetic dermatology patients are increasingly seeking hand rejuvenation procedures to eliminate appearance discrepancies between the face and hands, reported Ramin Fathi, MD, and Joel L. Cohen, MD, FAAD, who reviewed the benefits and complications of soft filler methods.

Pre-procedure evaluation includes assessing volume of lost fat from the skin via the Merz hand grading scale. Prior to augmentation, a detailed patient history, including medications, medical problems, and bleeding abnormalities, is typically taken, as well as assessment of patient lifestyle issues involving extensive hand activity, such as typing on a keyboard or playing piano. The authors reviewed three hand rejuvenation methods: autologous fat grafting, hyaluronic acid (HA), and poly-L-lactic acid (PLLA).

Although autologous fat grafting is still done in some practices, it is more invasive compared with soft tissue fillers, and can result in complications such as infection, cyst formation, temporary dysesthesia, and significant edema, the authors noted. PLLA is not approved for dorsal hand augmentation, and is used off label.

Hyaluronic acid (HA) fillers such as Restylane, Belotero, and Juvederm are approved only in the United States for facial soft tissue augmentation, and are also used off label for hand rejuvenation. The authors cited a small study of 16 patients evaluating small gel particle HA in the dorsal hand, in which vascular, tendon, bony prominence, and skin turgor were improved by 60.9%, 65.2%, 73.7%, and 26.3%, respectively, 2 weeks after treatment. “A distinct advantage of HA is that imperfections or undesired product can usually be reversed in the short term using hyaluronidase enzyme,” they added.

Despite the common adverse effects of erythema, pruritus, ecchymosis, and edema, “hand augmentation with soft tissue filler, alone or in conjunction with other rejuvenation modalities, can have a significant impact on improving appearance of the dorsal hands,” satisfying patient cosmetic objectives, the authors concluded.

Read the full article in the Journal of Drugs in Dermatology (J Drugs Dermatol. 2016;15[7]:809-15).

Cosmetic dermatology patients are increasingly seeking hand rejuvenation procedures to eliminate appearance discrepancies between the face and hands, reported Ramin Fathi, MD, and Joel L. Cohen, MD, FAAD, who reviewed the benefits and complications of soft filler methods.

Pre-procedure evaluation includes assessing volume of lost fat from the skin via the Merz hand grading scale. Prior to augmentation, a detailed patient history, including medications, medical problems, and bleeding abnormalities, is typically taken, as well as assessment of patient lifestyle issues involving extensive hand activity, such as typing on a keyboard or playing piano. The authors reviewed three hand rejuvenation methods: autologous fat grafting, hyaluronic acid (HA), and poly-L-lactic acid (PLLA).

Although autologous fat grafting is still done in some practices, it is more invasive compared with soft tissue fillers, and can result in complications such as infection, cyst formation, temporary dysesthesia, and significant edema, the authors noted. PLLA is not approved for dorsal hand augmentation, and is used off label.

Hyaluronic acid (HA) fillers such as Restylane, Belotero, and Juvederm are approved only in the United States for facial soft tissue augmentation, and are also used off label for hand rejuvenation. The authors cited a small study of 16 patients evaluating small gel particle HA in the dorsal hand, in which vascular, tendon, bony prominence, and skin turgor were improved by 60.9%, 65.2%, 73.7%, and 26.3%, respectively, 2 weeks after treatment. “A distinct advantage of HA is that imperfections or undesired product can usually be reversed in the short term using hyaluronidase enzyme,” they added.

Despite the common adverse effects of erythema, pruritus, ecchymosis, and edema, “hand augmentation with soft tissue filler, alone or in conjunction with other rejuvenation modalities, can have a significant impact on improving appearance of the dorsal hands,” satisfying patient cosmetic objectives, the authors concluded.

Read the full article in the Journal of Drugs in Dermatology (J Drugs Dermatol. 2016;15[7]:809-15).

Cosmetic dermatology patients are increasingly seeking hand rejuvenation procedures to eliminate appearance discrepancies between the face and hands, reported Ramin Fathi, MD, and Joel L. Cohen, MD, FAAD, who reviewed the benefits and complications of soft filler methods.

Pre-procedure evaluation includes assessing volume of lost fat from the skin via the Merz hand grading scale. Prior to augmentation, a detailed patient history, including medications, medical problems, and bleeding abnormalities, is typically taken, as well as assessment of patient lifestyle issues involving extensive hand activity, such as typing on a keyboard or playing piano. The authors reviewed three hand rejuvenation methods: autologous fat grafting, hyaluronic acid (HA), and poly-L-lactic acid (PLLA).

Although autologous fat grafting is still done in some practices, it is more invasive compared with soft tissue fillers, and can result in complications such as infection, cyst formation, temporary dysesthesia, and significant edema, the authors noted. PLLA is not approved for dorsal hand augmentation, and is used off label.

Hyaluronic acid (HA) fillers such as Restylane, Belotero, and Juvederm are approved only in the United States for facial soft tissue augmentation, and are also used off label for hand rejuvenation. The authors cited a small study of 16 patients evaluating small gel particle HA in the dorsal hand, in which vascular, tendon, bony prominence, and skin turgor were improved by 60.9%, 65.2%, 73.7%, and 26.3%, respectively, 2 weeks after treatment. “A distinct advantage of HA is that imperfections or undesired product can usually be reversed in the short term using hyaluronidase enzyme,” they added.

Despite the common adverse effects of erythema, pruritus, ecchymosis, and edema, “hand augmentation with soft tissue filler, alone or in conjunction with other rejuvenation modalities, can have a significant impact on improving appearance of the dorsal hands,” satisfying patient cosmetic objectives, the authors concluded.

Read the full article in the Journal of Drugs in Dermatology (J Drugs Dermatol. 2016;15[7]:809-15).

Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Retained Foreign Body

A 15-year-old male adolescent was brought to the ED by his father for evaluation of lacerations on the teenager’s left forearm, which were caused by a shattered glass door. The accident happened approximately 45 minutes prior to the patient’s arrival at the ED. The patient was up to date on all of his immunizations, including tetanus, and had no significant medical history.

On physical examination, the patient’s vital signs were all normal. He was noted to have two lacerations on the volar aspect of the distal one-third of his left forearm. One laceration measured 2.5 cm, running diagonally on the forearm; the other laceration was approximately 2 cm, running horizontally on the forearm. The bleeding from both wound sites was easily controlled with pressure.

The emergency physician (EP) did not document a neurological examination of the left wrist and hand. He did, however, note that the patient had a 2+ radial pulse and good capillary refill. The EP irrigated the wounds thoroughly and sutured the two lacerations. There was no documentation on file of wound  exploration or imaging studies. The patient returned 1 week after discharge from the ED for a wound check, and again 6 weeks later. On both occasions, he continued to complain of pain and decreased function of his left thumb and index finger.

Since the patient’s condition did not improve, his father took him to an orthopedic surgeon. The orthopedist ordered a magnetic resonance imaging (MRI) study of the left forearm, which demonstrated a complete tear of one of the patient’s flexor tendons. The orthopedist thought it was too late to repair the tendon and referred the patient to physical therapy. As the patient continued to complain of pain and decreased function of his left thumb, he consulted a second orthopedist, who decided to surgically explore the wound to determine the cause of the patient’s continued pain and loss of thumb function. Surgical exploration revealed a piece of glass measuring 3.5 x 2 cm retained in the patient’s forearm. The orthopedist removed the glass, irrigated the wound thoroughly, and closed the incision, after which the patient’s thumb function improved considerably and his pain resolved.

The patient’s family sued the EP and the hospital, arguing that the wound should have been explored and the glass removed on the initial ED visit. They further stated that if these steps were performed initially, the patient would not have required multiple imaging studies and surgery. At trial, the jury returned a defense verdict.

Discussion

Approximately 11 million wounds are treated in US EDs each year.¹ Proper management of lacerations and wounds requires more than sutures or staples. The EP must also evaluate for associated injuries (eg, tendon laceration, vascular injury), and the possibility of a retained foreign body. It is also important to ensure the patient is up to date on his or her tetanus immunization.

As with most areas of medicine, a good history and physical examination are essential. The mechanism of injury will often be the first clue to the risk of a retained foreign body. For example, shattered glass or porcelain carries a much higher risk of retention compared to a laceration from a box cutter.

The age of the injury is also important in determining the best management approach and the risk of infection. In a study by Brancto,¹ wounds closed within 19 hours of injury had a 92% rate of healing without infection, compared to only 77% of those closed after 19 hours. In addition, determination of a patient’s allergy status to anesthetics and antibiotics ensures safe and appropriate treatment.

On physical examination, the wound should be described in sufficient detail (eg, length, shape), and a distal neurovascular examination should be completed and documented. This involves testing the patient’s motor strength, sensation, adequacy of pulses, and capillary refill. When examining the extremities, flexion and extension strength should also be assessed and documented.

After a wound is prepped and anesthetized, it should be explored. Often a patient may have excellent flexor or extensor strength on testing, but have a near-complete tendon laceration on visual inspection. Similarly, the wound should be explored for foreign bodies. It is important to identify and remove foreign bodies because of the associated increased risk of infection, pain, and delayed healing.¹ Occasionally, a wound may need to be extended to remove a foreign body.

Unfortunately, visual inspection of a wound, especially a deep one, is not highly sensitive. If a physician has a high index of suspicion for a retained foreign body but is unable to identify one on examination, imaging studies should be ordered. Conventional plain radiography, ultrasonography, computed tomography (CT), and MRI studies can all be used to identify foreign bodies. Each of these modalities has its unique advantages and disadvantages. A recent study by Pattamapaspong et al² compared the accuracy of radiography, CT, and MRI in detecting foreign bodies in the foot. In this study, researchers placed various types of foreign bodies, including fresh wood, dry wood, glass, porcelain, and plastic—all measuring  5 x 2 mm— in cadaver feet.² The overall sensitivity and specificity for foreign body detection was 29% and 100%, respectively, for radiographs; 63% and 98%, respectively, for CT; and 58% and 100%, respectively, for MRI.² Interestingly, CT was superior to MRI in identifying water-rich fresh wood.² A similar study by Aras et al³ compared the sensitivity of plain radiographs, CT, and ultrasound in detecting foreign bodies in the face. The foreign bodies used in this study measured 1 x 1 x 1 cm and included metal, glass, wood, stone, acrylic, graphite, and polyoxybenzylmethylenglycolanhydride (ie, Bakelite).³ In this study, ultrasound identified superficial foreign bodies with low radiopacity in body tissues more effectively than CT or plain radiographs.³ In a review by Karabay⁴ of traumatic wrist and hand injuries, ultrasound was considered the best modality to identify and locate both opaque and radiolucent foreign bodies in the soft tissue.

If a foreign body is identified but cannot be removed, consultation with a surgical service is required. Depending on the local referral pattern, this might be general surgery, plastic surgery, or hand surgery. Unless there is an acute nerve or vascular injury, patients rarely require immediate surgery. In most cases, the wound can be closed loosely until the surgeon can remove the foreign body in the operating room and/or with aid of fluoroscopy at a later time. Depending on the size, material, and location of the foreign body, the surgeon might even elect to simply observe.

The bottom-line lesson from this case: depending on the mechanism of injury, EPs must maintain a high index of suspicion for retained foreign bodies in traumatic wounds. In addition to wound exploration, imaging studies should be used in patients at high risk for a retained foreign body, such as those injured with broken glass or porcelain, but in whom no foreign body is found on wound exploration.

Ruptured Esophagus

A 78-year-old man presented to the ED with symptoms of choking and chest discomfort. The patient stated that he had experienced a sudden onset of difficulty swallowing, along with chest pain, while he was eating dinner at a restaurant earlier that evening. The patient initially thought he had a piece of carrot stuck in his throat. He denied any previous history of similar symptoms. He complained of mild shortness of breath, but denied any drooling or vomiting. His medical history was significant for hypertension, which was controlled with medication. He denied tobacco or alcohol use and had no known drug allergies.

On physical examination, the patient’s vital signs were: heart rate (HR), 106 beats/minute; blood pressure (BP), 144/82 mm Hg; respiratory rate, 22 breaths/minute, and temperature, 98.6°F. Oxygen saturation was 95% on room air. The patient’s oropharynx appeared normal and without foreign body obstruction; his lungs were clear to auscultation bilaterally; and his HR was tachycardic but with a regular rhythm. Other than mild diaphoresis, the remainder of the physical examination was normal.

The EP ordered a complete blood count (CBC), a basic metabolic profile (BMP), and a portable chest X-ray, which the EP interpreted as normal. In addition, an intravenous (IV) saline lock was placed, and the patient was given morphine 4 mg IV and ondansetron 4 mg IV. He was also placed on 2 L of oxygen via nasal cannula. Since the patient continued to complain of chest pain and dysphagia, the EP consulted with a gastroenterologist; unfortunately, there was no documentation of this.

The EP admitted the patient to the floor with a diagnosis of esophageal obstruction, probably secondary to a piece of carrot. During the night, the patient’s shortness of breath worsened, requiring an increase in supplemental oxygen. The next morning, the patient’s HR increased to 120 beats/minute; his BP dropped to 96/50 mm Hg, and he developed a low-grade fever. He was transferred to the intensive care unit, where he was started on IV fluid resuscitation with normal saline and broad spectrum antibiotics. A CT scan of the chest was also ordered, which revealed an esophageal perforation. The patient was taken immediately to the operating room; surgery revealed a large esophageal perforation with evidence of mediastinitis and gross contamination of the left hemithorax. The patient died 2 days later.

The patient’s family sued the EP for failure to diagnose and treat the esophageal perforation in a timely manner. The EP argued that the patient’s symptoms were consistent with an obstruction, not esophageal perforation. The defendant also argued that the initial chest X-ray was normal. The case was resolved for $800,000 prior to going to trial.

Discussion

Esophageal perforation is a true medical emergency that requires timely diagnosis and management because morbidity and mortality are directly related to the time to treatment. Unfortunately, esophageal perforation can be a difficult diagnosis due to its relative rarity and variability in clinical presentation.

More than 50% of all esophageal perforations are iatrogenic, primarily as a complication of endoscopy.¹ Other causes of perforation include spontaneous perforation or Boerhaave syndrome (15%), foreign body (12%), trauma (9%), and malignancy (1%).¹ Anatomically, perforation tends to occur in the areas of the esophagus that are most narrow—eg, cricopharyngeus muscle, area of broncho-aortic constriction, and esophagogastric junction.¹

Food impactions, not surprisingly, tend to occur in these same areas of the esophagus. In addition, there are structural esophageal abnormalities that increase the risk of food impaction, including diverticula, webs, rings, strictures, achalasia, and tumors.² Since food impaction can result in an esophageal perforation, there is a significant overlap in the initial presentation of these two conditions. However, in cases of perforation, signs and symptoms of shock predominate as time progresses due to esophageal contents leaking into the mediastinal and pleural spaces.

Patients with a food impaction will often complain of an acute onset of dysphagia, difficulty in handling secretions, choking, drooling, retrosternal fullness, regurgitation of undigested food, and wheezing.² Perforation can cause severe chest pain, tachypnea, dyspnea, fever, and shock.²

A chest X-ray is typically the initial imaging study for suspected esophageal perforation. Since most spontaneous perforations occur through the left posterolateral wall of the distal esophagus, a new left pleural effusion can frequently be seen on X-ray. Mediastinal emphysema is highly suspicious for perforation, but the condition takes time to develop; therefore, its absence on X-ray does not exclude perforation. In the setting of a normal chest X-ray and ongoing esophageal symptoms, further investigation is required, usually via CT scan or endoscopy. Computed tomography, because of its availability and speed, is usually the preferred study to confirm the diagnosis.

Once an esophageal perforation is confirmed or is highly suspected, the patient will require IV fluid resuscitation, IV broad-spectrum antibiotic treatment, and emergency surgical consultation. As previously stated, esophageal perforation is associated with a high mortality rate, and time is critical to successful management.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Presenter: Kenneth Roberts, MD

One of PHM16’s most highly attended sessions was about anticipated updated from the American Academy of Pediatrics (AAP) to its guidelines for febrile infants ages 7¬–90 days. The proposed update stresses the need to separate individual components of serious bacterial infections (UTI, bacteremia, and meningitis) as the incidence and clinical course can vary greatly in this population.

The proposed inclusion criteria for infants for this algorithm require an infant to be full-term (37–43 weeks’ gestation), aged 7–90 days, well-appearing, and presenting with a temperature of 38°C. Proposed exclusion criteria include perinatal/prenatal/neonatal maternal fever, infection, or antimicrobial treatment; the presence of any evident infection; being technology-dependent; and the presence of congenital anomalies.

The proposed guideline update will aim to stratify management by ages 7–28 days, 29–60 days, and 61–90 days to provide the most appropriate and directed treatment. It will also include a role for inflammatory markers and allow for a “kinder, gentler” approach, including withholding certain treatments and procedures if infants are at low risk of infection. An active need for observation may be appropriate for certain infants as well.

Key Takeaway

It is likely that the AAP will update its algorithm for the management of well-appearing febrile infants ages 7–28 days, 29–60 days and 60–90 days. It will help standardize care in this population but should not be used as a substitute for clinical judgment. The new guidelines are expected to be published in early 2017.

Chandani DeZure, MD, FAAP, is a pediatric hospitalist at Children’s National Health System and instructor of pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

Rate of ED Deaths Drops by Nearly 50%

BY JEFF BAUER

FROM HEALTH AFFAIRS

The rate of ED deaths dropped by almost half from 1997 to 2011, according to recent analysis of a large database of ED visits.

Researchers evaluated data from the National Hospital Ambulatory Medical Care Survey, which is conducted annually by the National Center for Health Statistics and is the largest nationally representative database of information about emergency conditions in the United States. For the 1997 through 2011 study period, it provided data on 1.3 billion ED visits by patients ages 18 years and older. Using data from the US Census Bureau, researchers calculated the ED mortality rate per 1,000 US adults. Death in the ED also included individuals who were dead upon arrival.

There were 1.48 ED deaths per 1,000 adults in 1997 and .77 deaths per 1,000 adults in 2011, the most recent year for which data are available. This is a 48% reduction. Compared to patients who survived to ED discharge or hospital admission, those who died in the ED were older, had higher triage scores, and were more likely to be male and white. The proportion of patients who visited a rural ED or an ED in the South was higher among those who died than among those who survived. For roughly 63% of ED deaths, the patient was in cardiopulmonary arrest, unconscious, or dead on arrival.

The study was not designed to identify possible reasons for the reduction in ED deaths. The authors suggested it was likely due to multiple causes, including an increase in palliative care, less frequent use of resuscitation efforts in the prehospital setting, and improvements in emergency medicine and public health.

1.    Kanazaria HK, Probst MA, Hsia RY. Emergency department death rates dropped by nearly 50 percent, 1997-2011. Health Aff (Millwood). 2016;35(7):1303-1308.

AHA Issues Statement on Drugs That May Cause or Exacerbate Heart Failure

BY MITCHEL L. ZOLER

FRONTLINE MEDICAL NEWS

Many commonly used prescription drugs, many over-the-counter (OTC) agents, and several complementary or alternative medications can either trigger heart failure or exacerbate the disease in patients with existing heart failure, according to a scientific statement written by a committee of the American Heart Association (AHA).

This first-ever authoritative US overview of what is known about drugs that can affect heart failure was compiled to address an important practice issue for the large and growing number of US patients with heart failure, which is estimated to be nearly 6 million Americans, and “provide some guidance to healthcare providers in how to minimize polypharmacy, improve medication safety, as well as identify the medications that could exacerbate or cause heart failure,” said Robert L. Page II, PharmD, chair of the committee and a professor of clinical pharmacy at the University of Colorado at Denver, Aurora.

Although the comprehensive statement lists 88 distinct prescription drugs or drug classes as agents that pose major or moderate threats for causing or worsening heart failure, “from the American public’s perspective, importance should be placed on educating patients regarding the impact that OTC medications can have on their heart failure,” Dr Page said in an interview. “For example, nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen can cause sodium and water retention and antagonize the effects of evidence-based heart failure pharmacotherapies. Additionally, OTC medications like pseudoephedrine, which many cough and cold products contain, can increase blood pressure and afterload,” he noted. The risks these drugs pose become even greater when they are taken at higher doses.

The full text of the AHA statement is available at http://bit.ly/29ELCXz.

1.    Page RL 2nd, O’Bryant CL, Cheng D, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation. 2016 Jul 11. [Epub ahead of print] 

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

If you work on the front lines of medical care treating patients with hepatitis, you may not have time to review all the hepatitis research that enters the medical literature every month. Here’s a quick look at some notable news items and journal articles published over the past month, covering a variety of the major hepatitis viruses.

Although hepatitis E virus infections are increasingly recognized as a global public health problem, there are “few methods for prevention and treatment that are widely available,” according to a recent analysis.

©Zerbor/Thinkstock

A “suboptimal plasma level of the antiviral drug daclatasvir allows the selection of resistance-associated variants” and fails to contribute to antiviral activity in HIV-hepatitis C virus (HCV) coinfected patients, according to a recent study, although no definite reason for the low daclatasvir level was found.

The new preservative-free inactivated hepatitis A vaccine (Healive) in two doses showed better persistence of antibody concentrations for 5 years after full-course immunization among children, compared with Havrix. The endurance of protective immunogenicity was estimated for at least 20 years.

Because of transplacental transfer of antihepatitis B virus antibodies (anti-HBVs), high levels of maternal anti-HBVs may suppress infants’ immune response to standard HBV vaccination, according to an analysis in the Journal of Viral Hepatitis.

The gamma-glutamyl transpeptidase-to-platelet ratio (GPR) is “a new serum model for the diagnosis” of liver fibrosis and cirrhosis, according to a recent study. Researchers said it shows advantages in Chinese hepatitis Be antigen (HBeAg)-positive patients with hepatitis B virus DNA greater than or equal to 5 log10 copies/mL and ALT less than or equal to two times ULN (upper limit of normal), compared with APRI (aspartate aminotransferase to platelet ratio index) and Fibrosis-4.

A baseline quantitative hepatitis B surface antigen (HBsAg) threshold of 3.141 log10 IU/mL and a baseline quantitative hepatitis B core-related antigen 3.450 log10 U/mL threshold, used separately or in combination, allow prediction of response to pegylated interferon-alpha-2a (PegIFN)-based “precision therapy” for hepatitis B virus infection, a new study found.

Male sex, age over 40 years, cirrhotic liver, and long length of stay are significant factors associated with death in hepatitis A virus-hospitalized cases, according to a study in the Journal of Viral Hepatitis.

Chronic kidney disease patients receiving three doses of hepatitis B adjuvanted vaccine were three times more likely to seroconvert than patients immunized with nonadjuvanted vaccines, according to results of a Spanish study. This meant fewer patients needed a second course of HBV vaccination and there were fewer outpatient visits.

Acute kidney injury is closely linked with increased short-term mortality in Chinese hepatitis B virus-related, acute-on-chronic liver failure patients, according to a study in the Journal of Viral Hepatitis.

Italian investigators attempted “to predict susceptibility of healthy patients to de novo HBV infection using a cultured IFN-gamma enzyme-linked immunospot (ELISPOT) assay.” Although the prognostic value of the assay was not demonstrated, data suggested that the subjects may be at risk for HBV infection.

Investigators demonstrated that treatment with sofosbuvir and simeprevir was effective in a real-life cohort of patients with hepatitis C virus genotype 4 infection and advanced liver fibrosis/cirrhosis. They said that adding ribavirin could be considered in treatment-experienced patients.

The presence of specific anti-envelope antibodies may be a factor that helps individuals at high risk of hepatitis C virus to resist infection, according to a study in the Journal of Viral Hepatitis.

A Chinese study determined that certain social network structural characteristics are related to hepatitis C virus infections in people who inject drugs, and used the data to identify the most susceptible individuals for HCV transmission in a network of people who inject drugs.

Drug resistance analyses of protease inhibitors that treat hepatitis C virus infection can be useful and essential in revealing the particular variants responsible for pretreatment natural resistance and also the particular mutations responsible for the viral breakthrough that may develop during the treatment, according to a study in the International Journal of Infectious Diseases.

Routine vaccination of toddlers against hepatitis A virus would be cost effective in Mexico using a single-dose vaccination strategy, according to a recent study, although the authors said the cost efficacy of a second dose depends on the assumptions of added safeguards by immune memory protection and the time horizon over which the analysis is enacted.

Hepatitis C virus-infected patients undergoing ribavirin-free sofosbuvir and velpatasvir regimens had significantly better patient-reported outcome scores during therapy, compared with those undergoing the ribavirin-containing regimen, a recent study found.

An analysis in Infectious Diseases in Clinical Practice reported the first case of visual hallucinations during chronic hepatitis C treatment with sofosbuvir and simeprevir. Investigators said hallucinations stopped upon starting antipsychotic medication, and the remainder of treatment was safe.

Sustained virologic response can be attained with pegylated interferon-alpha plus ribavirin combination therapy in hepatitis C virus–infected patients, but a relapse may occur in some patients, according to a recent study.

A quantitative HBsAg test can be used to ascertain high levels of hepatitis B viremia in women who might transmit the virus to their children, rather than a test for HBeAg or HBV DNA, according to a research letter in Hepatology.

The prevalence of antihepatitis E virus (HEV) antibodies was 49% (153/313) among blood donors in central Italy, according to a study published in Eurosurveillance. The authors said HEV infection is hyperendemic among blood donors (80% men, 18- to 64-years-old) from central Italy and associated with local dietary habits, such as eating raw dried pig liver sausage.

[email protected]

On Twitter @richpizzi

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

Long-acting beta-2 agonists achieve better asthma control when added to inhaled corticosteroids in a fixed-dose combination, compared with use of a LABA as a separate inhaler, according to Steve Turner, MD, and his associates.

At baseline, 35% of children in the FDC ICS (fixed-dose combination inhaled corticosteroids)/LABA cohort and in the separate ICS+LABA cohort had achieved overall asthma control. After 2 years, 43% of children in the FDC ICS/LABA cohort had achieved overall asthma control, compared with 37% of children in the separate ICS+LABA cohort. The adjusted odds ratio for overall asthma control in the separate ICS+LABA cohort was 0.77.

The adjusted relative risk of acute respiratory events for the separate ICS+LABA cohort was 1.21, compared with the FDC ICS/LABA cohort, and the aRR for severe exacerbations was 1.31 for the separate ICS+LABA cohort. More children in the separate ICS+LABA cohort were treated with antibiotics; however, the incidence of thrush was higher in the FDC ICS/LABA cohort.

“This small effect may be partly explained by improvement in all outcomes in both groups as the children became older. An additional factor may be that adherence was relatively poor for all participants (22%-33%), and poor adherence is associated with poor control. This may have led to the decision to step up and also to a relatively disappointing response to treatment,” the investigators wrote.

Find the full study in the Journal of Allergy and Clinical Immunology (doi:10.1016/j.jaip.2016.06.009).

[email protected]

The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

[email protected]

On Twitter @richpizzi

The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

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The Centers for Disease Control and Prevention is providing $67 million to help U.S. health departments address antibiotic resistance and related patient safety concerns.

The new funding was made available through the CDC’s Epidemiology and Laboratory Capacity for Infectious Diseases Cooperative Agreement (ELC), according to a CDC statement, and will support seven new regional laboratories with specialized capabilities allowing rapid detection and identification of emerging antibiotic resistant threats.

James Gathany/CDC

The CDC said it would distribute funds to all 50 state health departments, six local health departments (Chicago, the District of Columbia, Houston, Los Angeles County, New York City, and Philadelphia), and Puerto Rico, beginning Aug. 1, 2016. The agency said the grants would allow every state health department lab to test for carbapenem-resistant Enterobacteriaceae and ultimately perform whole genome sequencing on intestinal bacteria, including Salmonella, Shigella, and many Campylobacter strains.

The agency intends to provide support teams in nine state health departments for rapid response activities designed to “quickly identify and respond to the threat” of antibiotic-resistant gonorrhea in the United States, and will support high-level expertise to implement antimicrobial resistance activities in six states.

The CDC also said the promised funding would strengthen states’ ability to conduct foodborne disease tracking, investigation, and prevention, as it includes increased support for the PulseNet and OutbreakNet systems and for the Integrated Food Safety Centers of Excellence, as well as support for the National Antimicrobial Resistance Monitoring System (NARMS).

Global partnerships

Complementing the new CDC grants was an announcement from the U.S. Department of Health & Human Services that it would partner with the Wellcome Trust of London, the AMR Centre of Alderley Park (Cheshire, U.K.), and Boston University School of Law to create one of the world’s largest public-private partnerships focused on preclinical discovery and development of new antimicrobial products.

According to an HHS statement, the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) will bring together “multiple domestic and international partners and capabilities to find potential antibiotics and move them through preclinical testing to enable safety and efficacy testing in humans and greatly reducing the business risk,” to make antimicrobial development more attractive to private sector investment.

HHS said the federal Biomedical Advanced Research and Development Authority (BARDA) would provide $30 million during the first year of CARB-X, and up to $250 million during the 5-year project. CARB-X will provide funding for research and development, and technical assistance for companies with innovative and promising solutions to antibiotic resistance, HHS said.

“Our hope is that the combination of technical expertise and life science entrepreneurship experience within the CARB-X’s life science accelerators will remove barriers for companies pursuing the development of the next novel drug, diagnostic, or vaccine to combat this public health threat,” said Joe Larsen, PhD, acting BARDA deputy director, in the HHS statement.

[email protected]

On Twitter @richpizzi