We present the case of a 23 year-old male who sustained an anterior tibial artery pseudoaneurysm after an apparently innocuous soccer injury. The patient presented with sudden onset severe pain and swelling one week after the injury. The diagnosis was made using duplex ultrasound, and confirmed with CT angiography. Definitive management consisted of endovascular platinum microcoiling. One year later, the patient is asymptomatic and remains active. A review of the epidemiology, diagnosis, and treatment of arterial pseudoaneurysm is presented. Bedside ultrasound in the emergency department may be a useful adjunct in the early identification of pseudoaneurysms.

Introduction: Heart failure (HF) is a common ED presentation that is associated with significant morbidity and mortality. Despite recent evidence and recommendations for early palliative care (PC) involvement in these patients, they are still significantly under-served by PC services, often resulting in multiple ED visits. We sought to evaluate use of PC services in patients with HF presenting to the ED. Secondary objectives of the study were to investigate: 1) one year mortality, ED visits, and admissions; 2) application of a novel palliative care referral score. Methods: We conducted a health records review of 500 consecutive HF patients who presented to two academic hospital EDs. We included patients aged 65 years or older who were diagnosed as having a HF exacerbation by the emergency physician (ICD-10 code 150.-). Our primary outcome was PC involvement. Secondary outcomes included one year mortality rates, ED visits, admissions to hospital, as well as the application of a novel PC referral score developed by the institutional cardiac Palliative Care Committee. The score consisted of 6 different aspects of the patient’s illness, including laboratory tests, hospital usage, and markers of decompensation. We conducted appropriate univariate analyses. Results: Patients were mean age 80.7 years, women (53.2%), and had significant comorbidities (atrial fibrillation (51.2%), diabetes (40.4%) and COPD (20.8%)). Compared to those with no PC, the 79 (15.8%) patients with PC involvement had a higher one year mortality rate (70.9% vs. 18.8%, p<0.0001), more ED visits/year for HF (0.82 vs. 0.52, p<0.0001), and more hospital admissions/year for HF (1.4 vs. 0.85, p<0.0001). Using the heart failure palliative care score criteria, 60 patients had scores >=2. Compared to those with scores <2, these patients had a higher 1-year mortality rate (50% vs. 24%, p<0.0001) and more ED visits/year for HF (0.83 vs. 0.54, p<0.01). Only 40.0% of these high risk patients had any PC involvement. Conclusion: We found that few HF patients had PC services involved in their care. Using this novel HF palliative care referral score, we were able to identify patients with a significantly greater risk of mortality and morbidity. This study provides evidence that the ED is an appropriate setting to identify and refer high risk HF patients who would likely benefit from earlier PC involvement and may be a future avenue for PC access for these patients.

Amber teething necklaces supposedly provide analgesia for teething infants. Their use is becoming more widespread, despite lack of peer-reviewed evidence and warnings from Health Canada that they pose a strangulation and aspiration risk. To date, there have been no published reports of strangulation secondary to amber teething necklaces. In this report we present a case of non-fatal infant strangulation from the first time use of an amber teething necklace. We will also discuss the role of physicians as advocates in reporting similar cases and educating families. Finally, we will comment on the responsibility of all professionals and professional organizations that work with infants and toddlers to advocate for children by raising concerns and counselling parents.

Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.

Introduction: 2.6% of emergency department (ED) syncope patients will have underlying cardiac serious conditions (e.g. arrhythmia, serious structural heart disease) identified within 30-days of disposition. If those at risk are discharged home, outpatient cardiac testing can detect underlying arrhythmias and structural heart disease, and thereby improve patient safety. We describe the frequency of outpatient referrals for cardiac testing and the proportion of cardiac serious adverse events (SAE) among high risk and non-high (low and medium) risk ED syncope patients, as defined by the Canadian Syncope Risk Score (CSRS). Methods: We conducted a multicenter prospective cohort study to enroll adult syncope patients across five large tertiary care EDs. We collected demographics, medical history, disposition, CSRS value, outpatient referrals and testing results (holter, echocardiography), and cardiac SAE. Adjudicated 30-day SAE included death due to unknown cause, myocardial infarction, arrhythmia, and structural heart disease. We used descriptive analysis. Results: Of 4,064 enrolled patients, a total of 955 patients (23%) received an outpatient referral (mean age 57.7 years, 52.1% female). Of the 299 patients (7%) hospitalized, 154 received outpatient cardiac testing after discharge. Among the 3,765 patients discharged home from the ED, 40% of the non-high risk patients (305/756) and 56% of the high risk patients (25/45) received outpatient cardiac testing. Of all patients who received outpatient cardiac testing, 4 patients (0.8%) had serious cardiac conditions identified and all were arrhythmias. Among those with no cardiac testing, 5 patients (0.9%) suffered cardiac SAE (80% arrhythmias) outside the hospital. Of the 20 (44%) high risk patients who did not receive outpatient cardiac testing, 2 (10%) patients suffered arrhythmias outside the hospital. While among the 451 non-high risk patients, only 0.8% suffered arrhythmia outside the hospital. Conclusion: Outpatient cardiac testing among ED syncope patients is largely underutilized, especially among high risk patients. Better guidelines for outpatient cardiac testing are needed, as current practice is highly variable and mismatched with patient risk.

Introduction: Chest pain is one of the most common presenting complaints to emergency departments (EDs) across the world, and the exclusion of acute myocardial infarction (AMI) using troponin testing is central to the care of many of these patients. Testing strategies using conventional troponin assays require repeat testing over many hours to avoid missed diagnoses. This study aims to validate the ability of very low concentrations of troponin at presentation to exclude AMI in ED chest pain patients. Methods: This prospective cohort study was conducted at a single urban tertiary centre and regional percutaneous coronary intervention site in Calgary, Alberta. Patients were eligible for enrolment if they presented to the ED with chest pain, were 25-years or older and required biomarker testing to rule out AMI at the discretion of the attending emergency physician. Patients were excluded if they had clear acute ischemic ECG changes, new arrhythmia or renal failure requiring hemodialysis. High-sensitivity troponin-T (Roche Elecsys hs-cTnT) results were obtained in all patients at presentation. Relevant outcomes were obtained from administrative data. The primary outcome was AMI within 30-days of ED visit, the secondary outcome was 30-day major adverse cardiac events (MACE). The study was REB approved. Results: A total of 1,016 patients were enrolled from August 2014-September 2016, of which 174 (17.1%) patients had an initial troponin below the limit of blank (<3 ng/L) and 369 (36.3%) had a level below the limit of detection (<5 ng/L). The sensitivity and negative predictive value (NPV) of a troponin below limit of blank (<3 ng/L) for 30-day AMI were 100% (95% CI 89.3%-100%) and 100% (95% CI 97.8-100%), respectively. The sensitivity and NPV of a troponin below limit of detection (<5 ng/L) for 30-day AMI were 93.8% (95% CI 80.0-98.3%) and 99.5% (95% CI 98.1-99.9%) respectively. Sensitivity for 30-day MACE at both cutoffs was lower: 96.1% (95% CI 92.5-98.0%) for <3 ng/L, and 88.4% (95% CI 83.3-92.1%) for <5 ng/L, respectively. Conclusion: A high sensitivity troponin T result below the limit of blank is highly sensitive at excluding AMI and identifies patients at reasonably low risk of 30-day MACE. A result below the limit of detection will identify a larger population of patients as low risk but has a greater risk of missed AMI and MACE.

A life-threatening cardiopulmonary resuscitation (CPR)-related injury can cause recurrent arrest after return of circulation. Such injuries are difficult to identify during resuscitation, and their contribution to failed resuscitation can be missed given the limitations of conventional CPR. Extracorporeal cardiopulmonary resuscitation (ECPR), increasingly being considered for selected patients with potentially reversible etiology of arrest, may identify previously occult CPR-related injuries by restoring arterial pressure and flow. Herein, we describe two cases of severe CPR-related injuries contributing to recurrent arrest. Each case had ECPR implemented within 60 minutes of the start of CPR. After the presumed cardiac etiology had been addressed with percutaneous coronary intervention, life-threatening cardiovascular injuries with recurrent arrest were noted, and resuscitative thoracotomy was performed under ECPR. One patient survived to hospital discharge.

ECPR may provide an opportunity to identify and correct severe resuscitation-related injuries causing recurrent arrest. Chest compression depth >6 cm, especially in older women, may contribute to these injuries.

Transient ischemic attacks (TIA) are a common presentation to the emergency department (ED) and are associated with an estimated 9% risk of stroke within 90 days.1 We report the case of a 72-year-old female who presented with orthostatic symptoms of facial weakness and dysarthria; that is, the patient’s symptoms were present when she was standing and resolved when supine. Neurological deficits present only when standing should alert the clinician to the importance of advanced neuroimaging to evaluate for acute arterial occlusion.