JEM reports最新文献

Background

Cerebrospinal fluid (CSF) xanthochromia, when diagnosed with spectrophotometry, is highly sensitive and specific for subarachnoid hemorrhage. However, most laboratories in North America currently rely on visual inspection rather than spectrophotometry for assessment of xanthochromia, making it less specific for the presence of hemoglobin degradation products and inclusive of other etiologies for yellow discoloration of the cerebrospinal fluid.

Case report

We present a series of cases from our inner-city community hospital to demonstrate how CSF xanthochromia is not specific to subarachnoid hemorrhage. There are three patients who presented with yellow-colored CSF but were ultimately diagnosed with meningitis or leptomeningeal carcinomatosis and one patient who presented with pink-colored CSF and was diagnosed with a true aneurysmal bleed.

Why should an emergency physician be aware of this

Subarachnoid hemorrhage is a life-threatening emergency that is always on an emergency physician's list of differential diagnoses in a patient with acute headache. Our series of cases suggest the importance of correctly interpreting lumbar puncture findings and relying on spectrophotometry rather than visual inspection of the CSF to rule xanthochromia—and, consequently, subarachnoid hemorrhage—in or out.

Ethylene glycol is a toxic alcohol, and its ingestion can cause neurological, cardiovascular, and renal complications, including coma and death. It causes an elevated osmolar gap, and its metabolites, glycolate, and oxalate, are responsible for elevated anion gap metabolic acidosis. Early diagnosis and management of this condition are critical in the emergency department (ED).

The point-of-care (POC) blood gas analyzer, commonly used in the emergency department, measures lactic acid using the lactate oxidase method, which measures the hydrogen peroxide generated from lactate. In contrast, the laboratory analyzer measuring venous lactate uses the lactate dehydrogenase method. Glycolic acid, a metabolite of ethylene glycol, is structurally similar to L-lactic acid, and it cross-reacts with lactate on the POC analyzer. Glycolic acid metabolized by lactate oxidase also leads to increased hydrogen peroxide production similar to L-lactic acid, resulting in spuriously elevated lactate. This discrepancy causes higher lactate levels in POC measurement than the laboratory-measured lactate, a condition called lactate gap.

We present two patients with altered levels of consciousness who had elevated osmolar gap and lactate gap at presentation to the emergency department. Ethylene glycol poisoning was suspected, given the discrepancy between POC lactate and laboratory-measured venous lactate levels. We promptly initiated treatment with fomepizole and hemodialysis while waiting for ethylene glycol levels, prompting early recovery.

We hypothesize that ED physicians should use the lactate gap as an initial diagnostic tool for early diagnosis of ethylene glycol poisoning, and hospitalists and nephrologists can use the closure of the lactate gap to decide on dialysis termination.

Background

Opioid drug overdose deaths are at an all-time high. Buprenorphine, a medication used to treat opioid use disorder, has dramatic effects on mortality after overdose as well as engagement with outpatient treatment programs. Recent regulatory changes have eased barriers to prescription, yet buprenorphine is infrequently prescribed from the emergency department. Objectives: Emergency physicians see patients who would benefit from this medication on a regular basis. We aim to illustrate how buprenorphine can be initiated from the emergency department.

Discussion

Using a series of six cases, the use of buprenorphine for common presentations of patients with opioid use disorder (OUD) is described.

Conclusions

We present a series of clinical vignettes in order to increase emergency physicians’ familiarity and comfort with the use of buprenorphine/naloxone in the treatment of OUD. Patients with OUD treated with buprenorphine/naloxone are less likely to die from overdose and more likely to engage in long-term treatment. Emergency departments are well suited to initiate buprenorphine/naloxone for patients who are ready for change and eligible for medications for OUD. Now that barriers to prescribing have been removed, emergency clinicians should seek out patients with opioid use disorder who may benefit from this life-saving treatment, initiated either in the ED or at home.

Background

Patients with cirrhosis are at risk for developing a number of complications, including hepatocellular carcinoma (HCC). The rupture of a neoplastic lesion can lead hemoperitoneum. Though rare, spontaneous intraabdominal bleeding is potentially fatal and requires prompt treatment. Computed tomography is the preferred imaging modality due to its ability to reveal the extent and source of the patient's bleeding.

Case report

We present an unusual case of a patient with cirrhosis presenting to the emergency department with chest and abdominal pain who was found to have hemoperitoneum from an apparent ruptured vessel within a HCC mass. While undergoing evaluation, the patient had spontaneous cessation of his bleeding.

Why should an emergency physician be aware of this?

Spontaneous hemoperitoneum resulting from HCC rupture is a rare and potentially fatal complication if not recognized promptly. This case illustrates the need for vigilance in treating this patient population and the complexity of their hemostatic status.

Background

Atrial Fibrillation (AF) is the most common sustained arrhythmia in the general population. Patients with atrial fibrillations commonly go to Emergency Departments (ED) with complications or aggravation of symptoms. They eventually receive rate or rhythm control intervention for rapid ventricular response and other interventions to prevent further worsening.

Case report

-We present a case of atrial fibrillation with rapid ventricular rate later found to have an undiagnosed gastrointestinal stromal tumor (GIST) along the lesser curvature, resulting in abrupt exsanguination. Initial symptoms were non-specific until manifesting acutely as new-onset atrial fibrillation with rapid ventricular response. Despite recovering sinus rhythm, unremitting evidence of concealed hemorrhagic shock directed attention toward occult bleeding. Emergent operative treatment controlled bleeding and prevented fatality.

Why should an emergency physician be aware of this?

An emergency physician should know this because atrial fibrillation does not always require acute rate/rhythm control. Newly diagnosed atrial fibrillation with rapid ventricular response in critically ill patients could be compensatory. Investigating underlying atrial fibrillation triggers can unveil precipitating factors. Occult shock demands urgent evaluation, as medications might precipitate overt shock and rapid deterioration. Even in cardiac patients, new-onset atrial fibrillation could be secondary.

Background

Choledochoduodenal fistula is a rare and poorly understood condition that results from the anomalous formation of a communicating tract between the common bile duct and the duodenum. While the precise etiology is not understood there has been a notable increase in identified cases in the last 20 years. The symptoms of choledochoduodenal fistula are vague and it is often not diagnosed until the patient develops cholangitis.

Case report

A 70yo M with a recent diagnosis of hepatitis C presented to the emergency department for evaluation of jaundice. Ultrasound demonstrated a hydropic gallbladder with “double duct” sign. The patient was admitted to the hospital and underwent ERCP. This identified a choledochoduodenal fistula which was treated. On follow up the patient had marked improvement with no significant sequelae or complications.

Why should an emergency physician be aware of this?

Choledochoduodenal fistula is a rare and poorly understood pathology. However, choledochoduodenal fistula “attacks” are strongly associated with cholangitis which has a mortality approaching 5 ​% even when appropriately managed (Sokal et al., Dec 2019) [1]. In our case, neither ultrasound nor portal vein-phased CT demonstrated the Choledochoduodenal fistula and ERCP was required both to identify and treat the fistula. In the setting of obstructive jaundice, it may be prudent for the emergency physician to consider transfer to a center with ERCP capability if it is not readily available in their facility.