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Project #114: Assessing the Gap: SIS Guidelines vs. Real-World Antibiotic Use in Facial Fractures
Get PDFhttps://scholarlycommons.henryford.com/qualityexpo2025/1019/thumbnail.jp
Project #147: Using Visual Management to Improve Compliance with Chlorohexidine Bathing and Nasal Decolonization
Get PDFhttps://scholarlycommons.henryford.com/qualityexpo2025/1027/thumbnail.jp
Project #149: Stay Home Safe: A Health and Housing Collaboration to Successfully Prevent Falls among Older Adults
Get PDFhttps://scholarlycommons.henryford.com/qualityexpo2025/1028/thumbnail.jp
A Case of Unresectable Necrosis
Get PDFIntroduction: Rectal necrosis is a rare phenomenon given profound collateral circulation. This carries significant morbidity and mortality. We present a case of acute rectal necrosis that is managed conservatively with surgical drainage. Case Description: A 53-year-old female with a history of peripheral arterial disease status post aorto-bifemoral bypass who presented in the emergency room with altered mental status and hypotension. She subsequently developed peritonitis prompting emergent surgical exploration. Her colon and rectum were noted be ischemic with patchy areas of necrosis. She underwent a total abdominal colectomy with an end ileostomy. The rectum was stapled at the rectosigmoid junction at peritoneal reflection and a drain was left in the pelvis. Repeat CT scan demonstrated breakdown of rectal staple line but no further intervention was required. She had a prolonged stay in the intensive care unit with a complicated postoperative course. Following her discharge, she was seen in the office and was recovering well. Discussion: Acute rectal necrosis can often be managed conservatively in the acute setting without the need for surgical resection. Wide drainage is essential to prevent abdominal sepsis. In addition, optimization of postoperative nutritional status is essential to promote healing and improve outcomes. Current evidence does not support the superiority of rectal resection, as it is associated with significant morbidity and mortality related to extent of the resection. However, in situations with frankly gangrenous rectum with concurrent pelvic sepsis there is no alternative to definitive source control in these patients. Conclusion: Acute rectal necrosis can occur in patients with severe atherosclerotic disease and hypoperfusion. Surgical resection is not always the best option, and can be managed conservatively with drainage and antibiotics. Resection should be reserved for patients with features of gangrene and pelvic sepsis with the understanding that this carries significant morbidity. Lessons Learned: Conservative management and drainage are an appropriate treatment for acute rectal necrosis.https://scholarlycommons.henryford.com/hfjhrs2025/1005/thumbnail.jp
Carotid Endarterectomy
No full textExtracranial carotid artery stenosis is accountable for 10–20% of all ischemic strokes. Carotid endarterectomy (CEA) prevents major stroke in patients presenting with focal transient ischemic attacks (TIAs) and minor stroke. Carotid endarterectomy can be performed under cervical block anesthesia (awake patient) or under general anesthesia. Most patients can undergo CEA safely without the use of indwelling shunt. In awake patients undergoing CEA under cervical block anesthesia, the need for indwelling shunt is approximately 10% and under GA with EEG monitoring is 12–18%. Post-carotid endarterectomy stroke occurs in 2–5% of patients undergoing CEA and is most often the result of plaque embolization. Post-CEA site thrombosis and intracerebral hemorrhage following CEA are other causes of postoperative stroke. Perioperative myocardial infarction, cranial nerve palsy, and hematoma in the neck are other complications of CEA
Cerebrovascular Imaging (CT, MRI, CTA, MRA)
No full textThere are a number of imaging modalities available for evaluating the vasculature of the head and neck, each of which has its own advantages and disadvantages for evaluating various disease processes. Thus, the clinical scenario and clinical question must be considered in choosing the most appropriate imaging modality. This chapter focuses on MR and CT techniques for cerebrovascular imaging and includes discussion about both the technical aspects and imaging findings of various pathologic processes
Preoperative Multivariable Model for Risk Stratification of Hypoxemia During One-Lung Ventilation
No full textBACKGROUND: Hypoxemia occurs with relative frequency during one-lung ventilation (OLV) despite advances in airway management. Lung perfusion scans are thought to be one of the most accurate methods to predict hypoxemia during OLV, but their complexity and costs are well-known limitations. There is a lack of preoperative stratification models to estimate the risk of intraoperative hypoxemia among patients undergoing thoracic surgery. Our primary objective was to develop a risk stratification model for hypoxemia during OLV based on preoperative clinical variables. METHODS: This is a single-center, retrospective cohort study including 3228 patients who underwent lung resections with OLV from 2017 to 2022, at a tertiary academic health care center in the United States. Vital signs and ventilator settings were retrieved minute by minute. Intraoperative hypoxemia was defined as an episode of oxygen desaturation (Spo2 \u3c90%) for at least 5 minutes. Demographic and clinical characteristics were included in a stepwise logistic regression, which was used for the selection of predictors of the risk score model. All patients included in this cohort underwent elective lung surgery in lateral decubitus position, with double lumen tube and placement confirmation with fiberoptic bronchoscopy. Our model was validated internally using area under the receiver operating curves (AUC) with bootstrapping correction. RESULTS: The incidence of hypoxemia during OLV was 8.9% (95% confidence interval [CI], 8.0-10.0). Multivariable logistic regression identified 9 risk factors with their corresponding scoring: preoperative Spo2 \u3c92% (15 points), hemoglobin \u3c10 g/dL (6 points), age \u3e60 years old (4 points), male sex (4 points), body mass index \u3e30 kg/m2 (8 points), diabetes mellitus (4 points), congestive heart failure (7 points), hypertension (3 points), and right-sided surgery (3 points). The AUC of the model after bootstrap correction was 0.708 (95% CI, 0.676-0.74). Based on the highest Youden index, the optimal score for predicting intraoperative hypoxemia was 13. The risk of hypoxemia increased from 4.7% in the first quartile of scores (0-13 points), to 32% in the third quartile (27-39 points), and 83.3% in the fourth quartile (\u3e39 points). At scores of 20 or greater, the specificity of the model exceeded 90% and reached a positive predictive value of 80%. CONCLUSIONS: The risk of hypoxemia during OLV can be stratified preoperatively using accessible clinical variables. Our risk model is well calibrated but showed moderate discrimination for predicting intraoperative hypoxemia. The accuracy of preoperative models for risk stratification of hypoxemia during OLV should be explored in prospective studies
Single-Access Technique for Impella-Assisted Balloon Aortic Valvuloplasty and High-Risk PCI in Cardiogenic Shock
No full textThe single-access technique for Impella-assisted high-risk percutaneous coronary intervention has been previously described and is frequently used in clinical practice to avoid a secondary arterial access and potentially reduce the risk of bleeding and vascular complications. Aortic stenosis associated with cardiogenic shock is associated with high morbidity and mortality. In this setting, Impella-supported balloon aortic valvuloplasty has been reported to be feasible and safe. In this case, we describe a technique for single-access Impella, balloon aortic valvuloplasty, and high-risk percutaneous coronary intervention for left main coronary artery disease in a patient with severe aortic stenosis and large body habitus presenting in cardiogenic shock
Contemporary Approach to Acute Pancreatitis in Emergency Medicine
No full textAcute pancreatitis is a commonly encountered pathology in the emergency department. We presented a clinical review summarizing the contemporary emergency medicine approach to managing acute pancreatitis. Although the diagnostic criteria for acute pancreatitis are straightforward, it has many possible causes, several treatment options, and both short- and long-term sequelae. We discussed diagnostic, intervention, and disposition considerations relevant to emergency clinicians and considered risk assessment using available clinical decision tools. We also discussed changes to traditional treatments and ongoing investigational therapies, including steroids, monoclonal antibodies, and calcium release-activated calcium channel inhibitors
Navigating Nonlinear Pathways: Challenges and Opportunities for Diversity, Equity, and Inclusion Leaders in Academic Emergency Medicine
No full textOBJECTIVES: Diversity, equity, and inclusion (DEI) leadership roles have grown in academic emergency medicine (EM). We sought to elucidate specific pathways to DEI leadership roles among current DEI leaders in academic EM.
METHODS: From March to May 2023, we conducted semistructured, qualitative interviews with DEI leaders in academic EM across 5 US regions to investigate their pathways to leadership. Participants were recruited via email using Accreditation Council for Graduate Medical Education-accredited EM residency websites and the Academy for Diversity and Inclusion in EM. After recording and transcribing the interviews, we used an inductive approach to identify major themes.
RESULTS: Of 56 DEI leaders contacted, 25 agreed to participate, and 21 were interviewed. The median (range) interview duration was 34 (25-63) minutes. Leadership titles included directors, chairs, vice chairs, committee chairs, chiefs, advisors, and deans. Three major themes emerged: (1) nonlinear pathways-participants reached DEI roles through informal assumption, volunteering, or self-creation, often without initial aspiration or compensation; (2) undefined roles and expectations-roles and responsibilities were often determined by leaders themselves, with advantages and disadvantages; (3) variable perceived value in promotions-participants felt DEI efforts were frequently undervalued in academic promotion, with mentorship highlighted as crucial for translating DEI activities into academic achievements.
CONCLUSION: Our study provides important insights not only into the pathways to DEI leadership among current leaders in academic EM but also into the challenges and opportunities DEI leaders perceive when navigating roles, responsibilities, and academic promotion