Pub Date : 2024-08-23DOI: 10.1016/j.jemrpt.2024.100113
Joshua Garmatter, Thomas Gezella, Carol Cunningham
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.
{"title":"Now you see it, now you don't: An unusual case of hemoperitoneum in a patient with cirrhosis","authors":"Joshua Garmatter, Thomas Gezella, Carol Cunningham","doi":"10.1016/j.jemrpt.2024.100113","DOIUrl":"10.1016/j.jemrpt.2024.100113","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Case report</h3><p>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.</p></div><div><h3>Why should an emergency physician be aware of this?</h3><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100113"},"PeriodicalIF":0.0,"publicationDate":"2024-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000439/pdfft?md5=526ee6242dd6697091e3e85db7d6fe6c&pid=1-s2.0-S2773232024000439-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142094823","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 : 2024-08-17DOI: 10.1016/j.jemrpt.2024.100108
Gabriella Miller, T. Andrew Windsor
{"title":"Woman with right eye injury","authors":"Gabriella Miller, T. Andrew Windsor","doi":"10.1016/j.jemrpt.2024.100108","DOIUrl":"10.1016/j.jemrpt.2024.100108","url":null,"abstract":"","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 4","pages":"Article 100108"},"PeriodicalIF":0.0,"publicationDate":"2024-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000385/pdfft?md5=31f3da92c90a8d36a5fee83726faa212&pid=1-s2.0-S2773232024000385-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142083063","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}
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.
{"title":"Racing hearts in the ED: When atrial tachyarrhythmias Herald hidden culprits","authors":"Anas Mohammed Muthanikkatt , Bukya Venkat Yogesh Naik , Muhsina Manayath Kunjumohammed , Anandhi Devendiran , Somasundaram Anukarthika , Senthamizhan Sundaramoorthy","doi":"10.1016/j.jemrpt.2024.100106","DOIUrl":"10.1016/j.jemrpt.2024.100106","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Case report</h3><p>-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.</p></div><div><h3>Why should an emergency physician be aware of this?</h3><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100106"},"PeriodicalIF":0.0,"publicationDate":"2024-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000361/pdfft?md5=5a3926f8d79044e95688f896001f624d&pid=1-s2.0-S2773232024000361-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141638353","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 : 2024-07-11DOI: 10.1016/j.jemrpt.2024.100107
Nicholas Cochran-Caggiano, Tom Weidman
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.
{"title":"“You mean it's not cancer?”: Choledochoduodenal fistula, a rare cause of biliary obstruction","authors":"Nicholas Cochran-Caggiano, Tom Weidman","doi":"10.1016/j.jemrpt.2024.100107","DOIUrl":"10.1016/j.jemrpt.2024.100107","url":null,"abstract":"<div><h3>Background</h3><p>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.</p></div><div><h3>Case report</h3><p>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.</p></div><div><h3>Why should an emergency physician be aware of this?</h3><p>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.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100107"},"PeriodicalIF":0.0,"publicationDate":"2024-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000373/pdfft?md5=079f8118decad318a57571b857ca3ba3&pid=1-s2.0-S2773232024000373-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141699422","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 : 2024-07-11DOI: 10.1016/j.jemrpt.2024.100105
Sarah D. Smetana , Nicholas E. Nacca , Rachel F. Schult , John DeAngelis
Background
Bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia is reported as a constellation of symptoms in critical care medicine known as “BRASH Syndrome.” It is reportedly a complex clinical scenario in which accumulated AV blockers and hyperkalemia result in bradycardia, renal failure, and shock interacting with each other synergistically.
Case report
A 70-year-old male taking metoprolol at home presented to the emergency department with hyperkalemia, cardiogenic shock, bradycardia, and renal failure. The patient was treated with routine treatment for shock (vasopressors), hyperkalemia (cardiac membrane stabilization, electrolyte temporization, and diuresis), and renal failure (dialysis) with eventual clinical resolution. A serum metoprolol concentration was obtained which was consistent with a therapeutic concentration. Why should the emergency physician be aware of this? The proposed BRASH syndrome may over-emphasize the role of AV nodal blockade in the presentation of patients with renal failure, hyperkalemia, and bradycardia. There is a limited list of renally-cleared medications that would be directly impacted by acute renal insufficiency. A common memory device for renally cleared beta blockers is NASA (nadolol, atenolol, sotalol, acebutolol). The suggestion of synergistic effect of hyperkalemia and therapeutic AV nodal blockade is speculative and lacks empiric evidence. The implication of potential supratherapeutic drug concentrations or even enhanced synergistic effects of a drug suggests a relative toxicity, which could mislead a clinician into considering toxicity state specific therapies such as high insulin euglycemia, glucagon, or lipid emulsion which carry adverse effect profiles and generally lack evidence to support use in these clinical presentations.
{"title":"Don't Be-RASH: A case report","authors":"Sarah D. Smetana , Nicholas E. Nacca , Rachel F. Schult , John DeAngelis","doi":"10.1016/j.jemrpt.2024.100105","DOIUrl":"10.1016/j.jemrpt.2024.100105","url":null,"abstract":"<div><h3>Background</h3><p>Bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia is reported as a constellation of symptoms in critical care medicine known as “BRASH Syndrome.” It is reportedly a complex clinical scenario in which accumulated AV blockers and hyperkalemia result in bradycardia, renal failure, and shock interacting with each other synergistically.</p></div><div><h3>Case report</h3><p>A 70-year-old male taking metoprolol at home presented to the emergency department with hyperkalemia, cardiogenic shock, bradycardia, and renal failure. The patient was treated with routine treatment for shock (vasopressors), hyperkalemia (cardiac membrane stabilization, electrolyte temporization, and diuresis), and renal failure (dialysis) with eventual clinical resolution. A serum metoprolol concentration was obtained which was consistent with a therapeutic concentration. Why should the emergency physician be aware of this? The proposed BRASH syndrome may over-emphasize the role of AV nodal blockade in the presentation of patients with renal failure, hyperkalemia, and bradycardia. There is a limited list of renally-cleared medications that would be directly impacted by acute renal insufficiency. A common memory device for renally cleared beta blockers is NASA (nadolol, atenolol, sotalol, acebutolol). The suggestion of synergistic effect of hyperkalemia and therapeutic AV nodal blockade is speculative and lacks empiric evidence. The implication of potential supratherapeutic drug concentrations or even enhanced synergistic effects of a drug suggests a relative toxicity, which could mislead a clinician into considering toxicity state specific therapies such as high insulin euglycemia, glucagon, or lipid emulsion which carry adverse effect profiles and generally lack evidence to support use in these clinical presentations.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100105"},"PeriodicalIF":0.0,"publicationDate":"2024-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S277323202400035X/pdfft?md5=85d961bdd9b3d1c37aea9e0c5652aa67&pid=1-s2.0-S277323202400035X-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141638355","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 : 2024-07-09DOI: 10.1016/j.jemrpt.2024.100103
Daniel L. Shaw , Bryan A. Stenson , Leon D. Sanchez , David T. Chiu
Background
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) pandemic disrupted medical education in many care settings, including the Emergency Department (ED). It is unclear what effects these changes have had on resident training and clinical productivity.
Objective
The purpose of this study is to determine Emergency Medicine (EM) resident productivity in the ED during the COVID-19 pandemic.
Methods
This was a retrospective observational study at an academic medical center with an EM residency program. Data were collected from the electronic medical record from 7/1/2017–10/31/2021. The primary outcome was patients per hour (PPH). Postgraduate year (PGY) 1 and 2 shifts were included. Analysis included descriptive statistics (mean ± standard deviation), correlation testing, and multivariate linear regression.
Results
Overall, PGY1 residents saw fewer PPH than PGY2 residents (1.00 ± 0.12 vs 1.40 ± 0.13 PPH, p < 0.001). During academic year (AY) 2019–2020, there was a trend towards lower resident productivity compared to pre-COVID (2017–2019) that was statistically significant at the PYG2 level (PGY1 0.96 ± 0.13, p = 0.06; PGY2 1.31 ± 0.10 PPH, p = 0.004). This difference resolved over the course of AY 2020–2021. Multivariate linear regression showed association of resident productivity with patient volume, month of residency, and year of residency.
Conclusion
The period surrounding the COVID-19 pandemic showed a trend towards decreased resident productivity during AY 2019–2020, which proved transient and resolved during AY 2020–2021. Resident productivity was associated with both month of training and ED volume. Additional research is needed to describe the long-term effects on the training environment during COVID-19 on physician productivity.
{"title":"Emergency medicine resident productivity during the SARS-CoV-2 disease 2019 (COVID-19) pandemic","authors":"Daniel L. Shaw , Bryan A. Stenson , Leon D. Sanchez , David T. Chiu","doi":"10.1016/j.jemrpt.2024.100103","DOIUrl":"10.1016/j.jemrpt.2024.100103","url":null,"abstract":"<div><h3>Background</h3><p>The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) pandemic disrupted medical education in many care settings, including the Emergency Department (ED). It is unclear what effects these changes have had on resident training and clinical productivity.</p></div><div><h3>Objective</h3><p>The purpose of this study is to determine Emergency Medicine (EM) resident productivity in the ED during the COVID-19 pandemic.</p></div><div><h3>Methods</h3><p>This was a retrospective observational study at an academic medical center with an EM residency program. Data were collected from the electronic medical record from 7/1/2017–10/31/2021. The primary outcome was patients per hour (PPH). Postgraduate year (PGY) 1 and 2 shifts were included. Analysis included descriptive statistics (mean ± standard deviation), correlation testing, and multivariate linear regression.</p></div><div><h3>Results</h3><p>Overall, PGY1 residents saw fewer PPH than PGY2 residents (1.00 ± 0.12 vs 1.40 ± 0.13 PPH, p < 0.001). During academic year (AY) 2019–2020, there was a trend towards lower resident productivity compared to pre-COVID (2017–2019) that was statistically significant at the PYG2 level (PGY1 0.96 ± 0.13, p = 0.06; PGY2 1.31 ± 0.10 PPH, p = 0.004). This difference resolved over the course of AY 2020–2021. Multivariate linear regression showed association of resident productivity with patient volume, month of residency, and year of residency.</p></div><div><h3>Conclusion</h3><p>The period surrounding the COVID-19 pandemic showed a trend towards decreased resident productivity during AY 2019–2020, which proved transient and resolved during AY 2020–2021. Resident productivity was associated with both month of training and ED volume. Additional research is needed to describe the long-term effects on the training environment during COVID-19 on physician productivity.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100103"},"PeriodicalIF":0.0,"publicationDate":"2024-07-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000336/pdfft?md5=01c7d2f77b3ebc287f8b0c0a9e5cc96e&pid=1-s2.0-S2773232024000336-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141638356","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 : 2024-07-08DOI: 10.1016/j.jemrpt.2024.100104
Negin Ceraolo , Megan Cook , Kristen Septaric , David Ceraolo , Erin Simon
Background
Angioedema is a non-pitting type of edema that involves subcutaneous tissue of the extremities, neck, face, lips, oral cavity, larynx, and gut that can be classified into hereditary or acquired forms. In the emergency department (ED), it is common for visceral angioedema to be undiagnosed due to similarity of presentation to other disorders.
Case Report
We present a case of a 65-year-old male with likely visceral angioedema due to underlying angiotensin-converting enzyme inhibitor use. He initially presented to an outside ED due to a nonspecific pruritic rash. He was discharged with a steroid prescription. The patient had another outside ED visit with the development of acute rapid facial swelling and shortness of breathing that progressed to respiratory distress. He was discharged again after a period of observation and treatment for anaphylaxis. Not long after, he developed gastrointestinal distress prompting his third visit to the ED, where he was diagnosed with visceral angioedema. Although the treatment of angioedema does not differ depending on the type, patients with more extensive presentation may require further monitoring.
Why should an emergency physician be aware of this?
Visceral angioedema is a rare complication and can easily be mistaken for other gastrointestinal pathology such as gastroenteritis. Emergency physicians need to understand the complexity of angioedema and the multiple organ systems that can be involved. Diligent review of patient medications and other historical factors that can cause angioedema and early treatment will lead to better outcomes for patients.
{"title":"A case of visceral angioedema diagnosed in the emergency department","authors":"Negin Ceraolo , Megan Cook , Kristen Septaric , David Ceraolo , Erin Simon","doi":"10.1016/j.jemrpt.2024.100104","DOIUrl":"https://doi.org/10.1016/j.jemrpt.2024.100104","url":null,"abstract":"<div><h3>Background</h3><p>Angioedema is a non-pitting type of edema that involves subcutaneous tissue of the extremities, neck, face, lips, oral cavity, larynx, and gut that can be classified into hereditary or acquired forms. In the emergency department (ED), it is common for visceral angioedema to be undiagnosed due to similarity of presentation to other disorders.</p></div><div><h3>Case Report</h3><p>We present a case of a 65-year-old male with likely visceral angioedema due to underlying angiotensin-converting enzyme inhibitor use. He initially presented to an outside ED due to a nonspecific pruritic rash. He was discharged with a steroid prescription. The patient had another outside ED visit with the development of acute rapid facial swelling and shortness of breathing that progressed to respiratory distress. He was discharged again after a period of observation and treatment for anaphylaxis. Not long after, he developed gastrointestinal distress prompting his third visit to the ED, where he was diagnosed with visceral angioedema. Although the treatment of angioedema does not differ depending on the type, patients with more extensive presentation may require further monitoring.</p></div><div><h3>Why should an emergency physician be aware of this?</h3><p>Visceral angioedema is a rare complication and can easily be mistaken for other gastrointestinal pathology such as gastroenteritis. Emergency physicians need to understand the complexity of angioedema and the multiple organ systems that can be involved. Diligent review of patient medications and other historical factors that can cause angioedema and early treatment will lead to better outcomes for patients.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100104"},"PeriodicalIF":0.0,"publicationDate":"2024-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000348/pdfft?md5=9bd308b74c8cd402bb5bcdb8fade6526&pid=1-s2.0-S2773232024000348-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141595171","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 : 2024-07-08DOI: 10.1016/j.jemrpt.2024.100102
Carlos Rodriguez , Dhara Rana , Ujas Shah
Background
Page kidney is a rare cause of secondary hypertension arising from a subcapsular hematoma or mass compressing the kidney leading to increased arterial hypertension. Common causes of expansive kidney parenchymal bleeding are due to blunt trauma or less often iatrogenic causes, such as renal biopsy. Most of the time the secondary hypertension is resolved by evacuating the hematoma by stopping the bleeding via renal arterial embolization (RAE).
Case report
We discuss a 23-year-old female with a past medical history of hypertension, chronic kidney disease, status post left renal biopsy three days prior to evaluation who presented to the emergency department with severe left flank pain. From initial evaluation in the emergency department, a large expansive subcapsular hematoma was identified on imaging suggesting Page kidney causing the hypertensive emergency. The patient was managed with renal arterial embolization to control bleeding and blood pressure medications.
Why should an emergency physician be aware of this
Emergency physicians should be able to identify this rare cause of secondary hypertension to initiate proper management. Immediate blood pressure control, imaging and appropriate consultations should be initiated. Identifying sources of active bleeding is crucial for definitive management as was in the case which we presented. Quick identification of Page kidney is crucial to managing life threatening secondary hypertension, preventing renal failure, and addressing any sources of active hemorrhage.
{"title":"Page kidney induced emergent hypertension status post renal biopsy a case report","authors":"Carlos Rodriguez , Dhara Rana , Ujas Shah","doi":"10.1016/j.jemrpt.2024.100102","DOIUrl":"10.1016/j.jemrpt.2024.100102","url":null,"abstract":"<div><h3>Background</h3><p>Page kidney is a rare cause of secondary hypertension arising from a subcapsular hematoma or mass compressing the kidney leading to increased arterial hypertension. Common causes of expansive kidney parenchymal bleeding are due to blunt trauma or less often iatrogenic causes, such as renal biopsy. Most of the time the secondary hypertension is resolved by evacuating the hematoma by stopping the bleeding via renal arterial embolization (RAE).</p></div><div><h3>Case report</h3><p>We discuss a 23-year-old female with a past medical history of hypertension, chronic kidney disease, status post left renal biopsy three days prior to evaluation who presented to the emergency department with severe left flank pain. From initial evaluation in the emergency department, a large expansive subcapsular hematoma was identified on imaging suggesting Page kidney causing the hypertensive emergency. The patient was managed with renal arterial embolization to control bleeding and blood pressure medications.</p></div><div><h3>Why should an emergency physician be aware of this</h3><p>Emergency physicians should be able to identify this rare cause of secondary hypertension to initiate proper management. Immediate blood pressure control, imaging and appropriate consultations should be initiated. Identifying sources of active bleeding is crucial for definitive management as was in the case which we presented. Quick identification of Page kidney is crucial to managing life threatening secondary hypertension, preventing renal failure, and addressing any sources of active hemorrhage.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100102"},"PeriodicalIF":0.0,"publicationDate":"2024-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000324/pdfft?md5=1b1fe3cf82986c55bcae860638a76601&pid=1-s2.0-S2773232024000324-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141622200","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 : 2024-07-06DOI: 10.1016/j.jemrpt.2024.100100
Erin L. Simon , Mary Bozsik , Micaela Abbomerato , Caroline Mangira , Jessica Krizo
Background
Globally, there have been more than 771 million confirmed cases of COVID-19 and more than 6.9 million deaths. The relationship between Covid-19 and pulmonary embolism (PE) has been well-established.
Objectives
We evaluated the correlation between normal D-dimer levels and negative findings on computed tomography pulmonary angiogram (CTPA) to assess its predictive value. Additionally, we determined the sensitivity and specificity of a D-dimer in COVID-19 (+) patients.
Methods
This was a retrospective cohort study of all adult patients presenting to one of 17 EDs within a large integrated healthcare system between March 1, 2020, and December 31, 2021, who were diagnosed with COVID-19 and had a D-dimer and CTPA as part of their clinical workup. This study includes EDs in urban, suburban, and rural areas. Sensitivity and specificity were calculated to assess the performance of D-dimer tests in discriminating those with and without PE. Multiple logistic regression was used to assess the effect of D-dimer test results in predicting PE.
Results
A total of 3133 patients were included in this study (Fig. 1). Of 3133 patients, 2846 (91 %) had an abnormal D-dimer, and 287 (9 %) had a normal D-dimer. In the group with the abnormal D-dimer, 145 (5 %) had a PE on CTPA. In the group with the normal D-dimer, 285 (99.3 %) patients did not have a PE on CTPA. The sensitivity of D-dimer in this population was 98.6 %, and the specificity was 9.5 %. Patients with abnormal D-dimer levels were 7.86 times more likely to have a PE.
Conclusion
In conclusion, our study found that PE could be safely excluded for COVID-19 (+) patients with a normal or age-adjusted D-dimer.
{"title":"Can a negative d-dimer rule out pulmonary embolism in patients with COVID-19?","authors":"Erin L. Simon , Mary Bozsik , Micaela Abbomerato , Caroline Mangira , Jessica Krizo","doi":"10.1016/j.jemrpt.2024.100100","DOIUrl":"10.1016/j.jemrpt.2024.100100","url":null,"abstract":"<div><h3>Background</h3><p>Globally, there have been more than 771 million confirmed cases of COVID-19 and more than 6.9 million deaths. The relationship between Covid-19 and pulmonary embolism (PE) has been well-established.</p></div><div><h3>Objectives</h3><p>We evaluated the correlation between normal D-dimer levels and negative findings on computed tomography pulmonary angiogram (CTPA) to assess its predictive value. Additionally, we determined the sensitivity and specificity of a D-dimer in COVID-19 (+) patients.</p></div><div><h3>Methods</h3><p>This was a retrospective cohort study of all adult patients presenting to one of 17 EDs within a large integrated healthcare system between March 1, 2020, and December 31, 2021, who were diagnosed with COVID-19 and had a D-dimer and CTPA as part of their clinical workup. This study includes EDs in urban, suburban, and rural areas. Sensitivity and specificity were calculated to assess the performance of D-dimer tests in discriminating those with and without PE. Multiple logistic regression was used to assess the effect of D-dimer test results in predicting PE.</p></div><div><h3>Results</h3><p>A total of 3133 patients were included in this study (Fig. 1). Of 3133 patients, 2846 (91 %) had an abnormal D-dimer, and 287 (9 %) had a normal D-dimer. In the group with the abnormal D-dimer, 145 (5 %) had a PE on CTPA. In the group with the normal D-dimer, 285 (99.3 %) patients did not have a PE on CTPA. The sensitivity of D-dimer in this population was 98.6 %, and the specificity was 9.5 %. Patients with abnormal D-dimer levels were 7.86 times more likely to have a PE.</p></div><div><h3>Conclusion</h3><p>In conclusion, our study found that PE could be safely excluded for COVID-19 (+) patients with a normal or age-adjusted D-dimer.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":"3 3","pages":"Article 100100"},"PeriodicalIF":0.0,"publicationDate":"2024-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000300/pdfft?md5=2ad8744c999457e51c3658c1dfac18a3&pid=1-s2.0-S2773232024000300-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141622199","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 : 2024-07-06DOI: 10.1016/j.jemrpt.2024.100101
Matthew Baniqued , Rahul Nene
Background
Hypercalcemia can present in myriad ways and has an extensive differential diagnosis. It can affect numerous different organ systems, resulting in an array of symptoms.
Report
We present the case of a 53-year-old female who presented to a rural emergency department with abdominal pain and vomiting. She was found to have a markedly elevated calcium level and an elevated lipase. Advanced imaging revealed a new lung mass. She was admitted to the hospital with a diagnosis of hypercalcemia of malignancy, with hypercalcemia-induced pancreatitis. She was treated with intravenous fluids, bisphosphonates, and calcitonin, and eventually discharged home with close follow up with an oncologist.
Why Should an Emergency Physician Be Aware of This
Hypercalcemia can result in severe end-organ damage or fatal dysrhythmia. Prompt treatment and identification of underlying pathology is essential to minimize morbidity and mortality.
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