Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.01.003
Matthew Robert Dernbach MD , Joseph E. Carpenter MD , Nihar Shah MBBS , George Benjamin Carter MD
Background
Serotonin toxicity is a well-described phenomenon that is commonly attributed to a variety of drug–drug combinations. Some unregulated herbal supplements have been implicated in the onset of serotonin toxicity, however, there is currently minimal literature available on the potential for black cohosh to contribute to rhabdomyolysis and serotonin toxicity, in spite of its known serotonergic properties.
Case Report
A middle-aged woman presented to the emergency department with serotonin toxicity and rhabdomyolysis shortly after taking black cohosh supplements in the setting of long-term dual antidepressant use. The serotonin toxicity and rhabdomyolysis resolved with IV fluids, benzodiazepines, and discontinuation of the offending drugs.
Why Should an Emergency Physician Be Aware of This?
Patients are sometimes not aware of how over-the-counter supplements might interact with their prescription medications. Female patients taking black cohosh to manage hot flashes and menopausal symptoms could be at risk for developing rhabdomyolysis and serotonin toxicity if they are also taking other serotonergic agents.
{"title":"Black Cohosh Interactions with Prescription Medications Associated with Serotonin Toxicity and Rhabdomyolysis: A Case Report","authors":"Matthew Robert Dernbach MD , Joseph E. Carpenter MD , Nihar Shah MBBS , George Benjamin Carter MD","doi":"10.1016/j.jemermed.2024.01.003","DOIUrl":"10.1016/j.jemermed.2024.01.003","url":null,"abstract":"<div><h3>Background</h3><p>Serotonin toxicity is a well-described phenomenon that is commonly attributed to a variety of drug–drug combinations. Some unregulated herbal supplements have been implicated in the onset of serotonin toxicity, however, there is currently minimal literature available on the potential for black cohosh to contribute to rhabdomyolysis and serotonin toxicity, in spite of its known serotonergic properties.</p></div><div><h3>Case Report</h3><p>A middle-aged woman presented to the emergency department with serotonin toxicity and rhabdomyolysis shortly after taking black cohosh supplements in the setting of long-term dual antidepressant use. The serotonin toxicity and rhabdomyolysis resolved with IV fluids, benzodiazepines, and discontinuation of the offending drugs.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>Patients are sometimes not aware of how over-the-counter supplements might interact with their prescription medications. Female patients taking black cohosh to manage hot flashes and menopausal symptoms could be at risk for developing rhabdomyolysis and serotonin toxicity if they are also taking other serotonergic agents.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139455969","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.01.002
Jeffrey R. Stowell MD , Levi Filler DO , Carl Mitchell MD , Ashkon Mahmoudi MD , Thomas Whiting DO , Carl Pastore MD , Matthew Kunz DO , Murtaza Akhter MD
Background
Management of acute shoulder dislocation in the emergency department (ED) is common.
Objective
This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED.
Methods
The study was a retrospective case–control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts.
Results
Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2–22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6–84.3%] vs. 68.0% [95% CI 56.8–77.8%]; p = 0.0220), discharged home from the ED (95.4% [95% CI 92.6–97.3%] vs. 84.0% [95% CI 74.4–91.0%]; p = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8–47.6%] vs. 29.3% [95% CI 19.9–40.4%]; p = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4–31.0%] vs. 45.3% [95% CI 34.4–56.7%]; p = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (p < 0.001).
Conclusions
The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.
背景急诊科（ED）处理急性肩关节脱位很常见。目的本研究描述了与急诊科肩关节脱位复位失败相关的比率、风险因素和住院时间（LOS）。结果在急诊室进行肩关节复位尝试的398例患者中，18.8%（75/398；95% CI 15.2-22.9%）的患者需要进行多次复位尝试。在首次确认成像中成功缩复肩关节的患者多为男性（80.2% [95% CI 75.6-84.3%] vs 68.0% [56.8-77.8%]，P= 0.0220），从急诊室出院回家的患者多为男性（95.4% [95% CI 92.6-97.3%] vs 84.0% [95% CI 74.4-91.0%]，P= 0.0004），使用牵引/反牵引技术（42.1% [95% CI 36.8-47.6%] vs 29.3% [95% CI 19.9-40.4%]，p= 0.0415），以及较少发生牵引前骨折（26.0% [95% CI 21.4-31.0%] vs 45.3% [95% CI 34.4-56.7%]，p= 0.0010）。首次确认造影成功的患者的平均住院时间比多次尝试者缩短了 2 小时 8 分钟（p <0.001）。此外，需要多次尝试的患者的 ED LOS 明显更长。对失败率和风险因素的了解可以提高医生的认识，并为今后评估减容成功验证方法的研究提供指导。
{"title":"Rate of Successful Shoulder Reduction on First Confirmatory Imaging in the Emergency Department","authors":"Jeffrey R. Stowell MD , Levi Filler DO , Carl Mitchell MD , Ashkon Mahmoudi MD , Thomas Whiting DO , Carl Pastore MD , Matthew Kunz DO , Murtaza Akhter MD","doi":"10.1016/j.jemermed.2024.01.002","DOIUrl":"10.1016/j.jemermed.2024.01.002","url":null,"abstract":"<div><h3>Background</h3><p>Management of acute shoulder dislocation in the emergency department (ED) is common.</p></div><div><h3>Objective</h3><p>This study describes the rate, risk factors, and length of stay (LOS) associated with shoulder dislocation reduction failure in the ED.</p></div><div><h3>Methods</h3><p>The study was a retrospective case–control study of patients 18 years and older presenting to the ED with acute shoulder dislocation who underwent attempted reduction. Patients with successful reduction on post-reduction first confirmatory imaging are compared with those requiring multiple attempts.</p></div><div><h3>Results</h3><p>Of 398 ED encounters when a shoulder reduction was attempted in the ED, 18.8% (75/398 [95% CI 15.2–22.9%]) required multiple reduction attempts. Patients with successful reduction on first confirmatory imaging were more commonly male (80.2% [95% CI 75.6–84.3%] vs. 68.0% [95% CI 56.8–77.8%]; <em>p</em> = 0.0220), discharged home from the ED (95.4% [95% CI 92.6–97.3%] vs. 84.0% [95% CI 74.4–91.0%]; <em>p</em> = 0.0004), reduced using a traction/countertraction technique (42.1% [95% CI 36.8–47.6%] vs. 29.3% [95% CI 19.9–40.4%]; <em>p</em> = 0.0415), and less likely to have a pre-reduction fracture (26.0% [95% CI 21.4–31.0%] vs. 45.3% [95% CI 34.4–56.7%]; <em>p</em> = 0.0010). Mean length of stay (LOS) for those with successful reduction on first confirmatory imaging was 2 hours and 8 minutes shorter than for those with more than one attempt (<em>p</em> < 0.001).</p></div><div><h3>Conclusions</h3><p>The rate of failed first-pass reduction is higher than previously reported. Furthermore, the ED LOS was significantly longer in patients requiring multiple attempts. Knowledge of the failure rate and risk factors may raise physician awareness and guide future studies evaluating approaches for verification of reduction success.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139579611","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Emergency medical services (EMS) transporting patients to the emergency department (ED) typically call ahead to provide an estimated time to arrival (ETA). Accurate ETA facilitates ED preparation and resource allotment in anticipation of patient arrival.
Objective
The study purposed to determine the accuracy of ETA provided by EMS ground units.
Methods
We performed a single-center, prospective, observational study of ED patients arriving via EMS ground transport. The primary outcome was the time difference between EMS-reported ETA and actual time of arrival (ATA). The difference between ATA and ETA was compared using the two-sided Wilcoxon Signed-Rank Test. Subgroup analysis was performed to evaluate ETA accuracy for specific types of transports and assess variability by month and time of day.
Results
We included 1176 patient transports in the final analysis. The overall median difference ATA-ETA was 3 min (interquartile range 1–5 min) with a range of −26–48 minutes (Z = −25.139, p < 0.001). EMS underestimated ETA in 961 cases (81.7%), and 94 ETAs (8.0%) were accurate to within 1 min. The largest difference between ATA and ETA occurred between 07:00–07:59 and 16:00–16:59 (5 min, interquartile range 2–7).
Conclusion
Our data demonstrate that prehospital providers underestimate time to ED arrival in most ground transports; however, the median difference between estimated and actual time to arrival is small.
背景急诊医疗服务（EMS）将患者送往急诊科（ED）时，通常会提前打电话提供预计到达时间（ETA）。准确的 ETA 有利于急诊科在病人到达前做好准备和资源分配。研究旨在确定急诊医疗服务（EMS）地面单位提供的预计到达时间（ETA）的准确性。主要结果是 EMS 报告的 ETA 与实际到达时间（ATA）之间的时间差。ATA 和 ETA 之间的差异采用双侧 Wilcoxon Signed-Rank 检验进行比较。我们还进行了分组分析，以评估特定类型转运的 ETA 准确性，并评估不同月份和时间的差异性。ATA-ETA 差值的总体中位数为 3 分钟（IQR 1-5 分钟），范围为 -26-48 分钟（Z=-25.139，p<0.001）。急救中心低估了961例（81.7%）的ETA，94例（8.0%）的ETA精确度在1分钟以内。ATA和ETA之间的最大差异出现在07:00-07:59和16:00-16:59之间（5分钟，IQR 2-7）。结论我们的数据表明，在大多数地面转运中，院前医疗服务提供者低估了到达急诊室的时间；但是，估计到达时间和实际到达时间的中位数差异很小。
{"title":"Accuracy of Prehospital Services' Estimated Time to Arrival for Ground Transport to the Emergency Department","authors":"Jessica Fozard DO, Brent Becker MD, Tucker Lurie MD, Aizad Dasti MD","doi":"10.1016/j.jemermed.2023.12.010","DOIUrl":"10.1016/j.jemermed.2023.12.010","url":null,"abstract":"<div><h3>Background</h3><p>Emergency medical services (EMS) transporting patients to the emergency department (ED) typically call ahead to provide an estimated time to arrival (ETA). Accurate ETA facilitates ED preparation and resource allotment in anticipation of patient arrival.</p></div><div><h3>Objective</h3><p>The study purposed to determine the accuracy of ETA provided by EMS ground units.</p></div><div><h3>Methods</h3><p>We performed a single-center, prospective, observational study of ED patients arriving via EMS ground transport. The primary outcome was the time difference between EMS-reported ETA and actual time of arrival (ATA). The difference between ATA and ETA was compared using the two-sided Wilcoxon Signed-Rank Test. Subgroup analysis was performed to evaluate ETA accuracy for specific types of transports and assess variability by month and time of day.</p></div><div><h3>Results</h3><p>We included 1176 patient transports in the final analysis. The overall median difference ATA-ETA was 3 min (interquartile range 1–5 min) with a range of −26–48 minutes (<em>Z</em> = −25.139, <em>p</em> < 0.001). EMS underestimated ETA in 961 cases (81.7%), and 94 ETAs (8.0%) were accurate to within 1 min. The largest difference between ATA and ETA occurred between 07:00–07:59 and 16:00–16:59 (5 min, interquartile range 2–7).</p></div><div><h3>Conclusion</h3><p>Our data demonstrate that prehospital providers underestimate time to ED arrival in most ground transports; however, the median difference between estimated and actual time to arrival is small.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138690493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/S0736-4679(24)00169-0
{"title":"American Academy of Emergency Medicine","authors":"","doi":"10.1016/S0736-4679(24)00169-0","DOIUrl":"https://doi.org/10.1016/S0736-4679(24)00169-0","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467924001690/pdfft?md5=cdc0a699456084c63e07d001b5e731a2&pid=1-s2.0-S0736467924001690-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140951626","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.01.012
Christiana K. Prucnal MD, ScM , Anne D. Isaacson MS , Annelise C. Prucnal MS
{"title":"Just a Ginger Ale","authors":"Christiana K. Prucnal MD, ScM , Anne D. Isaacson MS , Annelise C. Prucnal MS","doi":"10.1016/j.jemermed.2024.01.012","DOIUrl":"10.1016/j.jemermed.2024.01.012","url":null,"abstract":"","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139579864","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2023.12.008
Sun Young Lim MD, MSc , Sumin Baek MD , You Hwan Jo MD, PhD , Jae Hyuk Lee MD, PhD , Young Woo Um MD, MSc , Hee Eun Kim MD , Dongkwan Han MD
Background
There is a lack of evidence-based guidelines for the administration methods of ceftriaxone in emergency departments (EDs), resulting in the reliance on individual institutional protocols for decision-making.
Objective
This study was performed to compare the effects of administering ceftriaxone via intravenous push (IVP) and intravenous piggyback (IVPB) on 28-day mortality in patients with sepsis.
Methods
This was a retrospective study of patients aged 18 years or older with sepsis or septic shock who visited an ED and were treated with ceftriaxone as an initial antibiotic between March 2010 and February 2019. Patients were divided into the IVP group and the IVPB group based on the administration method. The primary outcome was 28-day mortality, and multivariable Cox proportional hazards regression analysis was performed to evaluate the relationship between antibiotic administration methods and 28-day mortality.
Results
During the study period, a total of 939 patients were included in the final analysis, and the overall mortality rate was 12.2%. The antibiotic administration time was significantly lower in the IVP group than in the IVPB group, and the rates of antibiotic administration within 1 h and within 3 h were higher in the IVP group than in the IVPB group (p < 0.05). However, there was no significant difference in 28-day mortality between the two groups (hazard ratio 1.07, 95% confidence interval 0.69–1.65).
Conclusions
IVP administration of ceftriaxone reduced the time of antibiotic administration compared with IVPB, but there was no difference in 28-day mortality.
{"title":"Effect of Intravenous Push and Piggyback Administration of Ceftriaxone on Mortality in Sepsis","authors":"Sun Young Lim MD, MSc , Sumin Baek MD , You Hwan Jo MD, PhD , Jae Hyuk Lee MD, PhD , Young Woo Um MD, MSc , Hee Eun Kim MD , Dongkwan Han MD","doi":"10.1016/j.jemermed.2023.12.008","DOIUrl":"10.1016/j.jemermed.2023.12.008","url":null,"abstract":"<div><h3>Background</h3><p>There is a lack of evidence-based guidelines for the administration methods of ceftriaxone in emergency departments (EDs), resulting in the reliance on individual institutional protocols for decision-making.</p></div><div><h3>Objective</h3><p>This study was performed to compare the effects of administering ceftriaxone via intravenous push (IVP) and intravenous piggyback (IVPB) on 28-day mortality in patients with sepsis.</p></div><div><h3>Methods</h3><p>This was a retrospective study of patients aged 18 years or older with sepsis or septic shock who visited an ED and were treated with ceftriaxone as an initial antibiotic between March 2010 and February 2019. Patients were divided into the IVP group and the IVPB group based on the administration method. The primary outcome was 28-day mortality, and multivariable Cox proportional hazards regression analysis was performed to evaluate the relationship between antibiotic administration methods and 28-day mortality.</p></div><div><h3>Results</h3><p>During the study period, a total of 939 patients were included in the final analysis, and the overall mortality rate was 12.2%. The antibiotic administration time was significantly lower in the IVP group than in the IVPB group, and the rates of antibiotic administration within 1 h and within 3 h were higher in the IVP group than in the IVPB group (<em>p</em> < 0.05). However, there was no significant difference in 28-day mortality between the two groups (hazard ratio 1.07, 95% confidence interval 0.69–1.65).</p></div><div><h3>Conclusions</h3><p>IVP administration of ceftriaxone reduced the time of antibiotic administration compared with IVPB, but there was no difference in 28-day mortality.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S0736467923005954/pdfft?md5=cd00b772c035a3f750704d9e29257d4a&pid=1-s2.0-S0736467923005954-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138679770","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2023.12.009
Maya Fontenot BA , Jake Valentine MD, MEd
Background
Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation.
Case Report
We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an “intrauterine gestational sac” along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy.
Why Should an Emergency Physician Be Aware of This?
This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to “clinically correlate.”
{"title":"Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report","authors":"Maya Fontenot BA , Jake Valentine MD, MEd","doi":"10.1016/j.jemermed.2023.12.009","DOIUrl":"10.1016/j.jemermed.2023.12.009","url":null,"abstract":"<div><h3>Background</h3><p>Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation.</p></div><div><h3>Case Report</h3><p>We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an “intrauterine gestational sac” along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to “clinically correlate.”</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138745283","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A minority of snake envenomations in the United States involve non-native snakes. In this report, we describe what we believe is the first documented human envenoming from an emerald horned pitviper, Ophryacus smaragdinus.
Case Report
A previously healthy 36-year-old woman was bitten on her left index finger by a captive emerald horned pitviper she was medicating at work. Swelling to the entire hand was present on emergency department arrival. She had no systemic symptoms and her initial laboratory studies were unremarkable. The affected limb was elevated. We administered five vials of Antivipmyn TRIⓇ (Bioclon), which specifically lists Ophryacus among the envenomations for which it is indicated. She developed pruritus and was treated with IV diphenhydramine and famotidine. Her swelling improved, but her repeat laboratory studies were notable for a platelet count of 102 K/µL and a fibrinogen level of 116 mg/dL. She declined additional antivenom because of the previous allergic reaction. She was admitted for further monitoring and pain control. Subsequent laboratory tests were better, but a small hemorrhagic bleb developed at the bite site. She was discharged the next day and followed up as an outpatient. Her swelling had resolved, her bleb had healed, and her laboratory studies continued to improve.
Why Should an Emergency Physician Be Aware of This?
Emergency physicians may be required to treat bites from non-native snakes. Many of these bites will warrant treatment with non–U.S. Food and Drug Administration–approved antivenoms. Consultation with a regional poison center or medical toxicologist may be necessary to procure the proper antivenom.
{"title":"Transient Hematotoxicity After Emerald Horned Pitviper (Ophryacus smaragdinus) Envenomation: A Case Report","authors":"Devin Shumway MD, Karen Pho MD, Nichole Andrews MD, Spencer Greene MD, MS","doi":"10.1016/j.jemermed.2024.01.010","DOIUrl":"10.1016/j.jemermed.2024.01.010","url":null,"abstract":"<div><h3>Background</h3><p>A minority of snake envenomations in the United States involve non-native snakes. In this report, we describe what we believe is the first documented human envenoming from an emerald horned pitviper, <em>Ophryacus smaragdinus</em>.</p></div><div><h3>Case Report</h3><p>A previously healthy 36-year-old woman was bitten on her left index finger by a captive emerald horned pitviper she was medicating at work. Swelling to the entire hand was present on emergency department arrival. She had no systemic symptoms and her initial laboratory studies were unremarkable. The affected limb was elevated. We administered five vials of Antivipmyn TRI<sup>Ⓡ</sup> (Bioclon), which specifically lists <em>Ophryacus</em> among the envenomations for which it is indicated. She developed pruritus and was treated with IV diphenhydramine and famotidine. Her swelling improved, but her repeat laboratory studies were notable for a platelet count of 102 K/µL and a fibrinogen level of 116 mg/dL. She declined additional antivenom because of the previous allergic reaction. She was admitted for further monitoring and pain control. Subsequent laboratory tests were better, but a small hemorrhagic bleb developed at the bite site. She was discharged the next day and followed up as an outpatient. Her swelling had resolved, her bleb had healed, and her laboratory studies continued to improve.</p></div><div><h3>Why Should an Emergency Physician Be Aware of This?</h3><p>Emergency physicians may be required to treat bites from non-native snakes. Many of these bites will warrant treatment with non–U.S. Food and Drug Administration–approved antivenoms. Consultation with a regional poison center or medical toxicologist may be necessary to procure the proper antivenom.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139458110","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-05-01DOI: 10.1016/j.jemermed.2024.01.006
Adesuwa Akhetuamhen MD , Kristin Bibbins-Domingo PHD, MD, MAS , Jahan Fahimi MD, MPH , Valy Fontil MD , Robert Rodriguez MD , Ralph C. Wang MD, MAS
Background
Fewer than one-half of U.S. adults with hypertension (HTN) have it controlled and one-third are unaware of their condition. The emergency department (ED) represents a setting to improve HTN control by increasing awareness of asymptomatic hypertension (aHTN) according to the 2013 American College of Emergency Physicians asymptomatic elevated blood pressure clinical policy.
Objective
The aim of the study was to estimate the prevalence and management of aHTN in U.S. EDs.
Methods
We examined the 2016–2019 National Hospital Ambulatory Medical Care Surveys to provide a more valid estimate of aHTN visits in U.S. EDs. aHTN is defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage. We then stratified aHTN into a 160–179/100–109 mm Hg subgroup and > 180/110 mm Hg subgroup and examined diagnosis and treatment outcomes.
Results
Approximately 5.9% of total visits between 2016 and 2019 met the definition for aHTN and 74% of patients were discharged home, representing an estimated 26.5 million visits. Among those discharged home, emergency physicians diagnosed 13% (95% CI 10.6–15.8%) and treated aHTN in 3.9% (95% CI 2.8–5.5%) of patients in the higher aHTN subgroup. In the lower aHTN subgroup, diagnosis and treatment decreased to 3.1% (95% CI 2.4–4.1%) and 1.2% (95% CI 0.7–2.0%), respectively.
Conclusions
Millions of ED patients found to have aHTN are discharged home without diagnosis or treatment. Although management practices follow clinical policy to delay treatment of aHTN, there are missed opportunities to diagnosis aHTN.
背景不到一半的美国成人高血压患者病情得到控制，三分之一的患者不知道自己的病情。根据 2013 年美国急诊医师学会无症状血压升高临床政策，急诊科（ED）是通过提高对无症状高血压（aHTN）的认识来改善高血压控制的场所。aHTN 被定义为在分诊和出院时血压≥ 160/100 mm Hg 且无外伤或内脏器官损伤迹象的成年患者。然后，我们将 aHTN 分为 160-179/100-109 mm Hg 亚组和 > 180/110 mm Hg 亚组，并检查了诊断和治疗结果。结果2016 年至 2019 年期间，约 5.9% 的总就诊人次符合 aHTN 的定义，74% 的患者出院回家，估计就诊人次为 2650 万。在出院回家的患者中，急诊医生诊断出 13%（95% CI 10.6-15.8%）的患者患有 aHTN，并为 3.9%（95% CI 2.8-5.5%）的高 aHTN 亚组患者进行了治疗。结论数以百万计的急诊室患者被发现患有 aHTN，但未经诊断或治疗便出院回家。尽管管理实践遵循临床政策，推迟了对 aHTN 的治疗，但还是错失了诊断 aHTN 的机会。
{"title":"Missed Opportunities to Diagnose and Treat Asymptomatic Hypertension in Emergency Departments in the United States, 2016-2019","authors":"Adesuwa Akhetuamhen MD , Kristin Bibbins-Domingo PHD, MD, MAS , Jahan Fahimi MD, MPH , Valy Fontil MD , Robert Rodriguez MD , Ralph C. Wang MD, MAS","doi":"10.1016/j.jemermed.2024.01.006","DOIUrl":"10.1016/j.jemermed.2024.01.006","url":null,"abstract":"<div><h3>Background</h3><p>Fewer than one-half of U.S. adults with hypertension (HTN) have it controlled and one-third are unaware of their condition. The emergency department (ED) represents a setting to improve HTN control by increasing awareness of asymptomatic hypertension (aHTN) according to the 2013 American College of Emergency Physicians asymptomatic elevated blood pressure clinical policy.</p></div><div><h3>Objective</h3><p>The aim of the study was to estimate the prevalence and management of aHTN in U.S. EDs.</p></div><div><h3>Methods</h3><p>We examined the 2016–2019 National Hospital Ambulatory Medical Care Surveys to provide a more valid estimate of aHTN visits in U.S. EDs. aHTN is defined as adult patients with blood pressure ≥ 160/100 mm Hg at triage and discharge without trauma or signs of end organ damage. We then stratified aHTN into a 160–179/100–109 mm Hg subgroup and > 180/110 mm Hg subgroup and examined diagnosis and treatment outcomes.</p></div><div><h3>Results</h3><p>Approximately 5.9% of total visits between 2016 and 2019 met the definition for aHTN and 74% of patients were discharged home, representing an estimated 26.5 million visits. Among those discharged home, emergency physicians diagnosed 13% (95% CI 10.6–15.8%) and treated aHTN in 3.9% (95% CI 2.8–5.5%) of patients in the higher aHTN subgroup. In the lower aHTN subgroup, diagnosis and treatment decreased to 3.1% (95% CI 2.4–4.1%) and 1.2% (95% CI 0.7–2.0%), respectively.</p></div><div><h3>Conclusions</h3><p>Millions of ED patients found to have aHTN are discharged home without diagnosis or treatment. Although management practices follow clinical policy to delay treatment of aHTN, there are missed opportunities to diagnosis aHTN.</p></div>","PeriodicalId":16085,"journal":{"name":"Journal of Emergency Medicine","volume":null,"pages":null},"PeriodicalIF":1.5,"publicationDate":"2024-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139458139","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
扫码关注我们
求助内容：
应助结果提醒方式：
京公网安备 11010802042870号