Background:Baseline neurocognitive assessment plays a critical role in return-to-play decision making following sport-related concussions. Prior studies have assessed the effect of a variety of modifying factors on neurocognitive baseline test scores. However, relatively little investigation has been conducted regarding the effect of pretest exercise on baseline testing.Purpose/Hypothesis:The aim of our investigation was to determine the effect of pretest exercise on baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores in adolescent and young adult athletes. We hypothesized that athletes undergoing self-reported strenuous exercise within 3 hours of baseline testing would perform more poorly on neurocognitive metrics and would report a greater number of symptoms than those who had not completed such exercise.Study Design:Cross-sectional study; Level of evidence, 3.Methods:The ImPACT records of 18,245 adolescent and young adult athletes were retrospectively analyzed. After application of inclusion and exclusion criteria, participants were dichotomized into groups based on a positive (n = 664) or negative (n = 6609) self-reported history of strenuous exercise within 3 hours of the baseline test. Participants with a positive history of exercise were then randomly matched, based on age, sex, education level, concussion history, and hours of sleep prior to testing, on a 1:2 basis with individuals who had reported no pretest exercise. The baseline ImPACT composite scores of the 2 groups were then compared.Results:Significant differences were observed for the ImPACT composite scores of verbal memory, visual memory, reaction time, and impulse control as well as for the total symptom score. No significant between-group difference was detected for the visual motor composite score. Furthermore, pretest exercise was associated with a significant increase in the overall frequency of invalid test results.Conclusion:Our results suggest a statistically significant difference in ImPACT composite scores between individuals who report strenuous exercise prior to baseline testing compared with those who do not. Since return-to-play decision making often involves documentation of return to neurocognitive baseline, the baseline test scores must be valid and accurate. As a result, we recommend standardization of baseline testing such that no strenuous exercise takes place 3 hours prior to test administration.

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The initial approach to burn injuries has remained relatively unchanged over the past several decades and revolves around trauma assessment and fluid resuscitation, frequently initiated in the emergency department (ED). While previous research suggests that emergency physicians (EP) are poor estimators at total body surface area (TBSA) affected, we believe that estimation differences are improving, specifically at academic centers with co-located burn units that emphasize burn injury education. This study investigated the interrater agreement and reliability of burn size estimations at an academic ED and its co-located burn unit. This single-center, retrospective study was conducted at a large academic ED with a co-located burn unit. The study included adult patients admitted to the burn unit after receiving paired burn size estimations from EPs and the burn unit. The primary endpoint was the interrater agreement, measured by the kappa coefficient, κ, of 10% TBSA estimation intervals. The secondary endpoint was the intraclass correlation coefficient (ICC), evaluating the reliability of exact, nonranged, and TBSA estimations. A chart review was performed for patients evaluated from November 1, 2016 to July 31, 2019. One thousand one hundred and eighty-four patients were admitted to the burn unit, 1176 of which met inclusion criteria for the primary endpoint. The κ of TBSA between EPs and the burn unit was 0.586, while the weighted κ was 0.775. These values correlate with moderate and substantial agreements, respectively. Additionally, 971 patients had exact TBSA estimations from paired EPs and the burn unit which were used for the secondary endpoint. The ICC between EPs and the burn unit was 0.966, demonstrating an excellent reliability. Further sub-analysis was performed, revealing mean over- and underestimation differences of exact TBSA estimations of 3.93 and 2.93, respectively. EPs at academic institutions with co-located burn units are accurate estimators of TBSA in the assessment of burn injuries. We believe that burn education, to include core rotations within the burn unit, plays a major role in improved burn size estimations.

Envenoming syndrome is an uncommon condition associated with significant morbidity and mortality following multiple Hymenoptera stings. We review the case of a 90-year-old male who presented after receiving greater than 100 bee stings and was found to have rhabdomyolysis with concomitant acute kidney injury. Physicians should consider envenoming syndrome in all patients presenting with greater than 50 bee stings, despite hemodynamically stability upon initial presentation.

Aortic dissection carries a high mortality of up to 40% at the time of initial dissection and an additional 1% per hour the dissection is untreated. Patients with acute aortic dissection most commonly present with chest or back pain. Less frequently, it manifests without pain with predominant neurologic symptoms secondary to an acute stroke. We present the case of a 53year-old male presenting with acute onset aphasia and right-sided weakness. Incidentally, CT angiography of his neck revealed a carotid artery dissection, which was found an extension of a Stanford type A acute aortic dissection resulting in a large vessel occlusion stroke. The patient's concomitant pathologies resulted in uncertainty as to the priority of management between the interventional neurology and cardiothoracic surgery services, ultimately resulting in the transfer of the patient to an aorta specialist at an outside facility. This case highlights several areas of difficulty in the management of patients with presenting with both large vessel occlusion stroke and acute aortic dissection and the need for consideration of acute aortic dissection in patients presenting with symptoms consistent with large vessel occlusion stroke. Optimal blood pressure control is unknown, as is the ideal timing of aortic repair and the potential for endovascular therapy for large vessel occlusion stroke in the setting of acute aortic dissection. Emergency physicians must rapidly engage with neurology, interventional neurology, and cardiothoracic surgery to determine appropriate interventions and timing of operative repair. The emergency physician must consider acute aortic dissection in patients presenting with signs and symptoms concerning for large vessel occlusion stroke, even if they have no complaint of chest pain, as administration of thrombolytics in these patients may be deadly.

Athletes with a history of self-reported seizure scored significantly lower on ImPACT visual motor speed compared to matched controls. As a solitary finding with a small effect size, the clinical significance of this difference is unclear. Apart from the decrease in visual-motor speed, this preliminary analysis suggests that athletes with a history of seizure might not have significantly different neurocognitive baseline test scores when compared with matched controls. Further empirical investigation is warranted to determine if a history of seizure is a modifying factor for SRC.

Study objectives This study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary‐care center. Methods We conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary‐care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters. The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned. Results The kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending. Conclusion This study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary‐care center.

Study Objectives: Emergency medical services (EMS) are an integral component of the health care system. Interaction with EMS and transition of patient care is a daily occurrence in emergency medicine (EM). EM learners present to residency with diverse levels of prior exposure and familiarity with EMS. Though the American College of Graduate Medical Education (ACGME) requires EM residents to have experience with EMS, emergency preparedness, and disaster management, there is significant variability in EMS curricula and training among residency programs. The goal of the exercise was to determine if a novel interdisciplinary education event, with focus on simulation and demonstration, increased EM resident and student knowledge of EMS systems and equipment as well as confidence interacting with EMS.Methods: A four-hour interactive, multidisciplinary simulation event was developed and held in the summer of 2020. EM residents and medical students rotated through multiple interactive stations that focused on EMS equipment and operations, online medical control, tactical EMS, and firefighting operations. Prior to the event, participants completed a survey to assess prior experiences, familiarity, and comfort with topics presented. An additional survey was provided at the completion of the event. Survey data was compared pre-and post-event to assess for change in responses. Items on the surveys were analyzed independently, and similar items were compared in aggregate. The post-event survey also assessed participants' perceptions of the exercise including organization and relevance.Results: 38 participants completed the pre-event survey; 27 completed the postevent survey with 23 participants identified and matched as answering both surveys. Composite scores showed a statistically significant improvement in learner confidence using the demonstrated EMS equipment and performing online medical control. Comfort with use of EMS equipment improved from an average of 3 to 4.33 (on a 1-5 Likert scale) after demonstration and practice with equipment. (p<0.0001). Average confidence providing online medical control improved from 1.33 to 2.67 (p<0.0001). Respondents indicated the event increased their familiarity with EMS, tactical EMS, and fire department operations. Post-survey perception data revealed that 100% of participants overall reviewed the event as well organized and enjoyable. 96% stated the exercise was relevant to emergency medicine. 93% stated they would use the knowledge gained in the experience in their future medical practice.Conclusion: This novel interdisciplinary educational event utilizing hands-on training and simulation was effective in increasing familiarity and confidence with EMS operations, equipment use and online medical control. Participants found the event to be a positive educational experience which increased their knowledge base and relevant to future medical practice. Further investigation comparing hands-on simulation exercises to classroom-based didactics would be instructive.