Pub Date : 2024-09-28DOI: 10.1016/j.jemrpt.2024.100118
Lingling Hou
Background
The seeds of Abrus precatorius are highly poisonous with no antidote available and are often consumed as a means of suicide. To date, there are no clear treatment strategies for Abrus poisoning induced by ingestion.
Case report
Here, we report a case in which a large number of Abrus precatorius seeds was successfully removed using gastrointestinal surgery to rescue the patient.
Why should an emergency physician be aware of this?
Abrus precatorius, as a rare but important cause of plant poisoning, is usually being unrecognized even by emergency physicians in China because of its scarce documentation in the Chinese medical literature. In managing such instances of intoxication, conventional gastric emptying techniques prove insufficient to effectively address the toxicity. Through this report, we hope to raise public awareness regarding this highly toxic plant. We also aim to offer a treatment reference for clinicians encountering similar situations.
{"title":"Surgical treatment for Abrus precatorius poisoning case","authors":"Lingling Hou","doi":"10.1016/j.jemrpt.2024.100118","DOIUrl":"10.1016/j.jemrpt.2024.100118","url":null,"abstract":"<div><h3>Background</h3><div>The seeds of <em>Abrus precatorius</em> are highly poisonous with no antidote available and are often consumed as a means of suicide. To date, there are no clear treatment strategies for Abrus poisoning induced by ingestion.</div></div><div><h3>Case report</h3><div>Here, we report a case in which a large number of <em>Abrus precatorius</em> seeds was successfully removed using gastrointestinal surgery to rescue the patient.</div><div>Why should an emergency physician be aware of this?</div><div><em>Abrus precatorius</em>, as a rare but important cause of plant poisoning, is usually being unrecognized even by emergency physicians in China because of its scarce documentation in the Chinese medical literature. In managing such instances of intoxication, conventional gastric emptying techniques prove insufficient to effectively address the toxicity. Through this report, we hope to raise public awareness regarding this highly toxic plant. We also aim to offer a treatment reference for clinicians encountering similar situations.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100118"},"PeriodicalIF":0.0,"publicationDate":"2024-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142426222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-26DOI: 10.1016/j.jemrpt.2024.100120
Mohammad Razban
Background
Mainly known as a cause of pulmonary infections or meningitis, Haemophilus influenzae has rarely been described as an etiology of urinary tract infections and even less as a cause of orchitis or epididymitis.
Case report
This paper describes a rare case of a patient who presented to our emergency department with urethral discharge, swelling of the right testicle, and fever consistent with a diagnosis of urethritis and orchepididymitis. Initially, we suspected a sexually transmitted disease such as chlamydia or gonorrhea. However, the urethral smear and urine culture revealed the presence of Haemophilus influenzae as the causative agent. A first therapy with Ceftriaxone and Azithromycin followed by doxycycline did not completely resolve symptoms. A new course of antibiotherapy with Ciprofloxacin led to complete remission.
Why should an emergency physician be aware of this?
Haemophilus influenzae can occasionally present with urethral discharge and symptoms of orchiepididymitis similar to those of a sexually transmitted disease. It is crucial for physicians to remember that this pathogen also causes genitourinary tract infections, given that most strains are resistant to Azithromycin. Consequently, they should adapt antibiotic therapy and investigations accordingly in these cases.
{"title":"Haemophilus influenzae urethritis and orchiepididymitis: A case report","authors":"Mohammad Razban","doi":"10.1016/j.jemrpt.2024.100120","DOIUrl":"10.1016/j.jemrpt.2024.100120","url":null,"abstract":"<div><h3>Background</h3><div>Mainly known as a cause of pulmonary infections or meningitis, Haemophilus influenzae has rarely been described as an etiology of urinary tract infections and even less as a cause of orchitis or epididymitis.</div></div><div><h3>Case report</h3><div>This paper describes a rare case of a patient who presented to our emergency department with urethral discharge, swelling of the right testicle, and fever consistent with a diagnosis of urethritis and orchepididymitis. Initially, we suspected a sexually transmitted disease such as chlamydia or gonorrhea. However, the urethral smear and urine culture revealed the presence of Haemophilus influenzae as the causative agent. A first therapy with Ceftriaxone and Azithromycin followed by doxycycline did not completely resolve symptoms. A new course of antibiotherapy with Ciprofloxacin led to complete remission.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>Haemophilus influenzae can occasionally present with urethral discharge and symptoms of orchiepididymitis similar to those of a sexually transmitted disease. It is crucial for physicians to remember that this pathogen also causes genitourinary tract infections, given that most strains are resistant to Azithromycin. Consequently, they should adapt antibiotic therapy and investigations accordingly in these cases.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100120"},"PeriodicalIF":0.0,"publicationDate":"2024-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142426221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-24DOI: 10.1016/j.jemrpt.2024.100119
Carlos Gonzalez-Cobos, Gabriel Rose
Background
Acute knee pain is a common presentation in the emergency department (ED), often necessitating effective and rapid pain relief to improve patient mobility and quality of life. Traditional analgesics may be insufficient, and regional anesthesia, such as genicular nerve blocks (GNB), offers a promising opioid-sparing alternative.
Objective
We present a case series of two patients who were successfully treated using ultrasound-guided GNB in the ED for acute knee pain.
Discussion
Ultrasound-guided GNB offers rapid pain relief, preserves motor function, and reduces the need for opioid analgesics. Further studies are warranted to confirm these findings and explore the broader applicability of this technique in emergency medicine.
Conclusion
Ultrasound-guided GNB is an effective and safe method for managing acute knee pain in the ED.
{"title":"Ultrasound-guided genicular nerve blocks for acute knee pain in the emergency department: A case series","authors":"Carlos Gonzalez-Cobos, Gabriel Rose","doi":"10.1016/j.jemrpt.2024.100119","DOIUrl":"10.1016/j.jemrpt.2024.100119","url":null,"abstract":"<div><h3>Background</h3><div>Acute knee pain is a common presentation in the emergency department (ED), often necessitating effective and rapid pain relief to improve patient mobility and quality of life. Traditional analgesics may be insufficient, and regional anesthesia, such as genicular nerve blocks (GNB), offers a promising opioid-sparing alternative.</div></div><div><h3>Objective</h3><div>We present a case series of two patients who were successfully treated using ultrasound-guided GNB in the ED for acute knee pain.</div></div><div><h3>Discussion</h3><div>Ultrasound-guided GNB offers rapid pain relief, preserves motor function, and reduces the need for opioid analgesics. Further studies are warranted to confirm these findings and explore the broader applicability of this technique in emergency medicine.</div></div><div><h3>Conclusion</h3><div>Ultrasound-guided GNB is an effective and safe method for managing acute knee pain in the ED.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100119"},"PeriodicalIF":0.0,"publicationDate":"2024-09-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142359043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-09-12DOI: 10.1016/j.jemrpt.2024.100117
Andrew Yocum , Ross Ferrise , Erin L. Simon
Background
Lateral canthotomy is a procedure performed emergently for orbital compartment syndrome (OCS) when a patient's intraocular pressure (IOP) becomes elevated beyond 40 mmHg. This ophthalmologic emergency usually occurs from a mass effect within the orbit, commonly from retro-orbital pressure due to bleeding or hematoma. Often, this causes proptosis and stretching of the optic nerve. As the pressure increases, vascular perfusion decreases, causing pain and decreased vision. Supra-orbital injuries causing OCS are rare, making early clinical detection challenging. Proptosis may not occur at all. Definitive treatment of OCS involves lateral orbital canthotomy and cantholysis (LOC) to alleviate pressure and restore blood flow.
Case report
A 65-year-old intoxicated male who presented to the emergency department after a ground-level fall. He was unable to report symptoms accurately and sustained a supraorbital hematoma while on clopidogrel. Despite lacking proptosis, the patient experienced a slow rise in IOP until peaking at 45 mmHg. Successful LOC resulted in immediate IOP reduction, and the patient was transferred for oculoplastic surgical evaluation.
Why should an emergency physician be aware of this?
OCS is an ophthalmologic emergency; treatment within 2 h is recommended to avoid permanent vision damage. When a patient is unable to communicate visual symptoms after trauma near the orbits, serial IOP measurements must be taken, even in the absence of clinical signs, until OCS can be definitively ruled out. If pressure rises above 40 mmHg, then an emergent LOC is indicated. This unique case underscores the diagnostic challenges of supraorbital OCS and emphasizes the importance of prompt LOC in preventing irreversible vision damage.
{"title":"Lateral canthotomy and cantholysis to relieve orbital compartment syndrome caused by a supraorbital hematoma","authors":"Andrew Yocum , Ross Ferrise , Erin L. Simon","doi":"10.1016/j.jemrpt.2024.100117","DOIUrl":"10.1016/j.jemrpt.2024.100117","url":null,"abstract":"<div><h3>Background</h3><div>Lateral canthotomy is a procedure performed emergently for orbital compartment syndrome (OCS) when a patient's intraocular pressure (IOP) becomes elevated beyond 40 mmHg. This ophthalmologic emergency usually occurs from a mass effect within the orbit, commonly from retro-orbital pressure due to bleeding or hematoma. Often, this causes proptosis and stretching of the optic nerve. As the pressure increases, vascular perfusion decreases, causing pain and decreased vision. Supra-orbital injuries causing OCS are rare, making early clinical detection challenging. Proptosis may not occur at all. Definitive treatment of OCS involves lateral orbital canthotomy and cantholysis (LOC) to alleviate pressure and restore blood flow.</div></div><div><h3>Case report</h3><div>A 65-year-old intoxicated male who presented to the emergency department after a ground-level fall. He was unable to report symptoms accurately and sustained a supraorbital hematoma while on clopidogrel. Despite lacking proptosis, the patient experienced a slow rise in IOP until peaking at 45 mmHg. Successful LOC resulted in immediate IOP reduction, and the patient was transferred for oculoplastic surgical evaluation.</div></div><div><h3>Why should an emergency physician be aware of this?</h3><div>OCS is an ophthalmologic emergency; treatment within 2 h is recommended to avoid permanent vision damage. When a patient is unable to communicate visual symptoms after trauma near the orbits, serial IOP measurements must be taken, even in the absence of clinical signs, until OCS can be definitively ruled out. If pressure rises above 40 mmHg, then an emergent LOC is indicated. This unique case underscores the diagnostic challenges of supraorbital OCS and emphasizes the importance of prompt LOC in preventing irreversible vision damage.</div></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100117"},"PeriodicalIF":0.0,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142426223","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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.
{"title":"The presentation and diagnostic utility of xanthochromia in current practice","authors":"Marzia Maliha , Paulina Henriquez-Rojas , Varsha Muddasani , Narges Rahimi , Stella Adetokunbo , Saman Zafar","doi":"10.1016/j.jemrpt.2024.100116","DOIUrl":"10.1016/j.jemrpt.2024.100116","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Case report</h3><p>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.</p></div><div><h3>Why should an emergency physician be aware of this</h3><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100116"},"PeriodicalIF":0.0,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000464/pdfft?md5=06b6b2cc2c96e3f5f04a86cab04c39c2&pid=1-s2.0-S2773232024000464-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142148076","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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.
{"title":"Lactate gap - A clinical tool for diagnosing and managing ethylene glycol poisoning","authors":"Prathap Kumar Simhadri , Nikhil Reddy Daggula , Ujjwala Murari , Prabhat Singh , Vivekanand Pantangi , Deepak Chandramohan","doi":"10.1016/j.jemrpt.2024.100111","DOIUrl":"10.1016/j.jemrpt.2024.100111","url":null,"abstract":"<div><p>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).</p><p>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.</p><p>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.</p><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100111"},"PeriodicalIF":0.0,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000415/pdfft?md5=f198abe8444b6fb60d3acc8847493ddc&pid=1-s2.0-S2773232024000415-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142094822","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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.
{"title":"Buprenorphine/naloxone initiation in the emergency department: A series of vignettes","authors":"Margarita Popova , Karen Chung , Sumitha Raman , Sonal Batra , Damali Nakitende , Keith Boniface","doi":"10.1016/j.jemrpt.2024.100112","DOIUrl":"10.1016/j.jemrpt.2024.100112","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Discussion</h3><p>Using a series of six cases, the use of buprenorphine for common presentations of patients with opioid use disorder (OUD) is described.</p></div><div><h3>Conclusions</h3><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100112"},"PeriodicalIF":0.0,"publicationDate":"2024-08-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000427/pdfft?md5=184d57bcb51e818d97462b65cedad3da&pid=1-s2.0-S2773232024000427-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142122468","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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