Objectives Acute dyspnea is a common presenting complaint to the emergency department (ED), and point‐of‐care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B‐lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. Methods A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In‐Process & Other Non‐Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand‐searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case‐control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B‐lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B‐lines. A final diagnosis from clinical follow‐up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS‐2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. Results Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B‐lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. Conclusions This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B‐lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.

Patient: Female, 19-year-oldFinal Diagnosis: Status epilepticus and stress induced cardiomyopathySymptoms: SeizureMedication: —Clinical Procedure: —Specialty: ToxicologyObjective:Unusual clinical courseBackground:Synthetic cannabinoids have a higher affinity for the cannabinoid receptors CB1 and CB2 than natural cannabinoids. Their use can be associated with cardiovascular disease and neurological complications. A case is reported of status epilepticus and stress cardiomyopathy following the recreational use of the synthetic cannabinoid, UR-144.Case Report:A 19-year-old woman presented to the emergency department in status epilepticus after smoking the synthetic cannabinoid known as ‘space’. Recurring seizure activity was controlled after three hours. On hospital day 3, the patient developed severe biventricular failure. Cardiac magnetic resonance imaging (MRI) confirmed the diagnosis of stress cardiomyopathy. A comprehensive urine drug screen was performed using gas chromatography-mass spectrometry (GC-MS), which was positive for UR-144, or (1-pentyl-1H-indol-3-yl) (2,2,3,3-tetramethylcyclopropyl)-methanone, and negative for all other illicit recreational drugs. The patient improved at one week following admission, with a left ventricular ejection fraction (LVEF) of 40%. She was discharged home on hospital day 10.Conclusions:The use of the synthetic cannabinoid, UR-144, may be associated with prolonged status epilepticus and stress cardiomyopathy. Physicians should be aware of these potentially lethal complications associated with the recreational use of this and other illicit synthetic cannabinoids.

Background: In a series of cases that came to be recognized as a national methanol outbreak, an incident of delay in allocation and treatment with the antidote fomepizole is described with aim of sharing a learning experience.Method: A team of 16 members was formed to conduct a Root Cause Analysis (RCA), which included multiple individual interviews with the stakeholders and inspection visits to the area.Results: Root causes: The restocking process was unclear and inconsistent and specifically lacked a restocking policy for antidotes, inappropriate labeling and area design, and a sound-alike between fomepizole and omeprazole. Contributing factors included: unsuitable restocking practice and lack of training in using the pharmaceutical electronic inventory system. Corrective actions were recommended and implemented.Conclusion: Management of antidotes in large healthcare systems requires a team effort to ensure appropriate and timely availability in emergency poisoning cases. This RCA identified important areas for improvement that could be insightful to other institutions in preventing similar vulnerabilities and is unique in describing the details of system improvements that can have a large impact on patient safety.

Noninferiority (NI) trials aim to show that a new treatment or drug is not inferior to a standard, accepted treatment. The rapid proliferation of NI trials within the literature makes it imperative for emergency physicians to be able to read, interpret, and appraise critically this type of research study. Using several emergency medicine examples from the recent literature, this article outlines the key differences between traditional, superiority randomized controlled trials and NI trials. We summarize four important points that an emergency physician should consider when critically appraising an NI trial: 1) Does the new treatment have tangible benefits over the standard treatment? 2) Was the choice of the NI margin appropriate? 3) Was the effect of the standard treatment preserved? Does the trial have assay sensitivity? and 4) What type of analysis strategy was employed: intention-to-treat (ITT) or per protocol (PP)? RÉ SUMÉLes essais de non-infé riorité (ENI) visent à dé montrer qu'un nouveau traitement ou un nouveau mé dicament n'est pas infé rieur au traitement de ré fé rence, reconnu. La prolifé ration des ENI dans la documentation rend impé rative la capacité des urgentologues à comprendre, à interpré ter et à é valuer d'un oeil critique ce type de recherche. Ainsi, l'article fera ressortir, à l'aide de plusieurs exemples tiré s de la documentation ré cente en mé decine d'urgence, les principales diffé rences qui existent entre le modè le classique d'essai comparatif, hasardisé , de supé riorité , et le modè le d'ENI. Seront ré sumé s quatre points importants qu'un urgentologue devrait envisager lorsqu'il é value de faç on critique un ENI: 1) Le nouveau traitement offre-t-il des avantages tangibles comparativement au traitement habituel? 2) Le choix de l'intervalle de non-infé riorité est-il pertinent? 3) L'effet du traitement de ré fé rence est-il conservé ? L'essai est-il sensible? 4) Quel type de straté gie d'analyse a é té employé : selon l'intention de traiter ou selon le protocole?

Background: About 65% of poisoning cases are related to children and of these, more than half of the patients are 5-year-old or less. While non-accidental poisoning is rare. We report two cases of intentional salbutamol poisoning in two young siblings presenting separately multiple times over a period of two years with similar presentations of tachycardia, hyperglycemia and hypokalemia. Case Presentation: Two siblings, one 3-year-old boy and the other one, 1 year old girl, presented at emergency department. Both presented with tachycardia and vomiting, while the boy also had hyperglycemia and hypokalemia, and girl also had subjective fever and poor oral intake. Other vital signs, physical examination, HbA1c, genome sequence, and upper GI tract examination were all normal. Child protective team were called due to suspension of Salbutamol toxicity and lab work confirmed it. The mother was interviewed who became resentful and refused to undergo any psychological assessment and left the hospital with children. The mother is suspected of Munchausen syndrome by proxy. Conclusion: Emergency medicine physicians should scrutinize over medication side effects and presentation. Active investigation to recognize similar cases of suspected Munchausen Syndrome by proxy in Saudi community is also warranted. Policymakers should introduce protocol to deal with victims and affected families.

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Patient: Female, 29-year-old Final Diagnosis: Spontaneous coronary artery dissection Symptoms: Cardiac arrest Medication: — Clinical Procedure: — Specialty: Critical Care Medicine Objective: Unknown etiology Background: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction, and the literature is undecided on the etiology, predisposing factors, and susceptible populations involved. SCAD is a disease that is under-recognized, underdiagnosed, and mainly affects young women of reproductive age. It has the highest incidence in the third trimester and postpartum period. Case Report: We present a case of a 29-year-old woman who was brought by family members to our Emergency Department (ED) in Riyadh, Saudi Arabia with sudden cardiac arrest due to SCAD in the right coronary artery 13 days after normal spontaneous vaginal delivery. The patient was brought in with no cardiopulmonary resuscitation for 20 min. She was resuscitated successfully in the ED. Her initial rhythm was ventricular fibrillation (VF). Point-of-care ultrasound (PoCUS) was performed during pulse checks, which revealed no signs of right ventricular strain nor signs of deep vein thrombosis (DVT). After that, she underwent primary percutaneous coronary intervention, which confirmed the diagnosis of right coronary artery dissection. The patient was successfully managed and discharged from the hospital after 18 days. She was independent and in good health after 4 months of follow-up. Conclusions: A high index of suspicion, familiarity with predisposing factors for SCAD, and PoCUS may play a critical role in detecting and managing SCAD patients.