Takotsubo syndrome (TS) is an incompletely understood, transient dysfunction of the left ventricle. While acute coronary syndrome must be at the forefront of the differential diagnosis and ruled out appropriately, the possibility of TS can be identified early with point-of-care ultrasonography. The formal diagnostic criteria for TS rely on invasive diagnostic procedures and resolution of symptoms, typically relegating it to a diagnosis of exclusion. However, the acute complications are potentially lethal, and rapid identification is therefore beneficial because these patients can be riskstratified to higher levels of care. Our case series of three patients, each with early suspected and subsequently confirmed TS, explores how early emergency department ultrasonography can suggest the diagnosis during the emergent workup, and potentially influence disposition decisions, subsequent interventions, and possibly even outcomes.

Case Presentation: An elderly man presented to the emergency department after a fall from a 15-foot height. Initial examination revealed signs of head and neck trauma without airway compromise. Computed tomography imaging identified cervical fractures at the first and second level with a retropharyngeal hematoma. In discussion with the trauma service, the patient was admitted to the hospital for airway monitoring. After 10 hours he clinically deteriorated, resulting in acute respiratory failure, and ultimately required intubation. The patient was intubated with a hyperangulated video laryngoscopy, and a surgical set-up was also prepared. The intubation was uncomplicated and resulted in clinical improvement. The patient was extubated after three days without difficulty and was ultimately discharged following an uncomplicated hospital course. Discussion: Retropharyngeal hematoma is a rare but significant clinical condition. Rapid decline and airway compromise have been described. Patients often require intubation and mechanical ventilation to avoid airway obstruction and respiratory failure. Coagulopathies should be reversed, if present. Prompt recognition and treatment of this condition is crucial to successful management.

Our ED-intensive care unit has instituted a new protocol meant to maximise the safety of physicians, nurses and respiratory therapists involved with endotracheal intubation of patients known or suspected of being infected with the novel SARS-CoV-2. The level of detail involved with this checklist is a deviation from standard intubation practices and is likely unfamiliar to most emergency physicians. However, the two-person system used in our department removes the cognitive burden such complexity would otherwise demand and minimises the number of participants that would typically be exposed during endotracheal intubation. We share this checklist to demonstrate to other departments how adopting international airway guidelines to a specific institution can be achieved in order to promote healthcare worker safety.

Objectives A lifelong pursuit such as medicine is frequently paired with a framework of “deliberate practice” for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a difference exists in the quality of feedback delivered to high‐, expected‐, and below‐expected performer emergency medicine (EM) residents based on their attending‐identified performance level. Methods We conducted a retrospective review of written EM resident feedback collected between November 2018 and March 2021. Clinical performance level was subjectively determined by attending faculty in their feedback. Feedback was coded on a scale from 0–5 based on the presence (1) or absence (0) of the items modified from the Ende's SMART criteria: Specific (S), Measurable (M), Achievable (A), Relevant (R), and Time‐bound (T). The primary outcome was any total modified SMART criteria score difference concerning performance level using logistic regression with Generalized Estimating Equations (GEE). Secondary outcomes were differences for individual criteria. Results We analyzed 1284 evaluations (311 high performers, 930 expected performers, and 43 below‐expected performers) of 94 unique residents from 66 different evaluators. Mean total modified SMART scores were significantly higher in high and below‐expected performers than those designated as expected performers by faculty evaluators. Achievable and Relevant written feedback was provided to high performers in a significantly larger proportion than expected and below‐expected performers. Only 278 out of 1284 evaluations met criteria for Specific. Conclusions Mean total modified SMART feedback scores were significantly greater in high performers and below‐expected performers when compared to expected performers. Achievable and Relevant feedback was provided in greater proportions to high performer residents compared to expected and below‐expected performers. These findings are a challenge to academic faculty to engage in quality feedback delivery for residents at all performance levels.

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