A 21-year-old man with Marfan syndrome and known aortic root aneurysm presented to our emergency department with symptoms suggestive of acute aortic dissection. The patient was hemodynamically stable and bilateral upper extremity blood pressures were similar. There was no mediastinal widening on portable chest radiograph. Both contrast CT and retrograde angiography of the aorta failed to identify dissection. Subsequent transesophageal echocardiography demonstrated a Stanford classification type A dissection. This case demonstrates the utility of multiple imaging modalities for identifying aortic dissection in high-risk patients.

Pediatric stroke is a rare disorder with a paucity of evidence-based treatment options, and can result in significant morbidity and mortality. In contrast to adult acute ischemic stroke, where the use of recombinant tissue plasminogen activator (rt-PA) has been studied in several large, randomized clinical trials, no high-level evidence exists for the use of thrombolytics in children with stroke. We report a case of a 15-year-old girl who suffered an acute ischemic stroke and had a dramatic improvement in symptoms following the administration of intravenous rt-PA.

How do we define competence in emergency medicine (EM), and how do we know when a resident has achieved it? In recent years, the idea of physician competence has become widely recognized as being multidimensional. This has resulted in an emphasis on competency-based education and assessment. We describe an up-to-date model to assess competence in EM. An overview of appropriate EM assessment tools is provided, along with their significant strengths and limitations. Sample behaviours representative of core competencies commonly assessed in EM training are matched to appropriate assessment tools. This review may serve as an introductory resource for EM clinicians, teachers and educators involved in EM trainee assessment.

A 21-year-old woman presented to the emergency department 1 day after a fall. On the day of presentation, she awoke with horizontal diplopia and posterior neck pain. Based on clinical findings, she was diagnosed with bilateral internuclear ophthalmoplegia. A conventional angiogram identified a left vertebral artery dissection. She was started on anticoagulant therapy, with gradual improvement of her diplopia over several months. Diplopia is frequently seen in the emergency department. Internuclear ophthalmoplegia is a cause of binocular diplopia and is important to recognize because it indicates a brainstem lesion requiring neurologic evaluation.

A child presenting with petechiae and fever is assumed to have meningococcemia or another form of bacterial sepsis and therefore to require antibiotics, blood cultures, cerebrospinal fluid analysis and hospital admission. A review of the literature challenges this statement and suggests that a child presenting with purpura (or petechiae), an ill appearance and delayed capillary refill time or hypotension should be admitted and treated for meningococcal disease without delay. Conversely, a child with a petechial rash, which is confined to the distribution of the superior vena cava, is unlikely to have meningococcal disease. Outpatient therapy in this context is appropriate. In other children, a reasonable approach would be to draw blood for culture and C-reactive protein (CRP) while administering antibiotics. If the CRP is normal, these children could be discharged to follow-up in 1 day, whereas children with CRP values greater than 6 mg/L would be admitted.