JEM reports最新文献

Background

We present the case of a 70-year-old woman who experienced an episode of posterior reversible encephalopathy syndrome (PRES) triggered by hyperlithiemia and hypernatremia.

Case repor

t: This case report describes a 70-year-old woman with bipolar disorder who presented at the Emergency Department (ED) with posterior reversible encephalopathy syndrome (PRES) triggered by hyperlithiemia and hypernatremia. Although lithium treatment is commonly prescribed for bipolar disorder, the exact mechanisms underlying lithium-induced PRES are still under investigation. The patient's altered consciousness prompted toxicological consultation, leading to a diagnosis of PRES associated with lithium toxicity. The patient required intensive care and received hydration therapy, resulting in a gradual reduction of sodium and lithium levels. After a period of rehabilitation, she was discharged with minimal neurological deficits.

"Why should an emergency physician be aware of this?"

Hyperlithiemia is an extremely rare cause of PRES (Posterior Reversible Encephalopathy Syndrome), which, if unrecognized, can have serious consequences and long-term effects on the patient.

Background

Confirming the placement of an endotracheal tube in a pediatric patient is a critically important step in resuscitation, and no single method of confirmation has been proven to be completely reliable. Capnography has become the standard-of-care in confirming endotracheal tube placement in many institutions and guidelines. However, it has inherent limitations in critically ill patients.

Case report

Two pediatric patients presented with acute hypoxemic respiratory failure in the emergency department and both underwent endotracheal intubation with video laryngoscopy. Post-intubation capnography showed no evidence of end-tidal carbon dioxide production. The clinicians assumed a misplaced endotracheal tube for both patients despite multiple emergency physicians simultaneously visualizing the endotracheal tube being placed through the vocal cords on the video laryngoscopy monitor. Both patients subsequently underwent multiple repeated intubations for over 30 minutes without any change in capnography findings. In one case, the reason for the lack of capnography findings was incorrectly connected capnography tubing; for the other, a positive capnography finding was only visualized after surfactant administration allowed adequate ventilation.

Why should an emergency physician be aware of this?

Capnography, though a valuable tool, is not an infallible method of endotracheal tube placement confirmation. Sole reliance on one method of confirmation, particularly in light of other compelling evidence—eg, clear visualization of tube passage through the vocal cords by multiple experienced physicians—should be avoided.

Background

Bisphosphonates are an antiresorptive agent approved to treat numerous skeletal disorders, including osteoporosis (postmenopausal and steroid-induced), malignancy-associated bone disease, and Paget's bone disease. The three most commonly used intravenous (IV) bisphosphonates for these treatments are zoledronate, ibandronate, and pamidronate. IV bisphosphonates for PMO have the advantage of better adherence to treatment compared to daily oral therapy.

Case report

A 77-year-old female patient presented to the emergency department (ED) with complaints of nausea and vomiting for one day. In the patient's history, it was learned that she had been using 4 mg zoledronic acid IV every four weeks for three months. Symptomatic hyponatremia was detected according to the patient's laboratory results and clinic. Since the patient had symptomatic hyponatremia, 150ml 3 ​% sodium chloride infusion was given. In addition, hydration was continued as she had metabolic alkalosis due to vomiting. The patient, whose symptoms decreased, was hospitalized for follow-up and treatment.

Why should an emergency physician be aware of this?

ED physicians and other clinicians should be aware that gastrointestinal symptoms such as nausea and vomiting may occur after intravenous administration of zoledronate and that symptoms may be the cause or result of hyponatremia. In these cases, laboratory examinations, appropriate treatments, and hospitalization should be performed for the necessary patients.

Background

There is conflicting data about sex-based differences in the treatment of acute pain in the ED. Little is known about sex-based disparities in analgesia in pediatric ED patients.

Objectives

Our objective was to determine whether analgesic administration rates differ between female and male pediatric patients presenting to the ED with abdominal pain.

Methods

We conducted a retrospective cohort study of ED patients 5–21 years old with abdominal pain between 6/1/19 and 6/30/21. The primary outcome was receipt of any analgesia, and secondary outcomes were receipt of opioid analgesia and time to receipt of analgesia. Multivariable regression models were fitted for each outcome.

Results

We studied 1087 patients; 681 (63%) were female with a median age of 17 years (IQR 13, 19) and 406 (37%) were male with a median age of 14 years (IQR 9, 18). 371 female patients (55%) and 180 male patients (44%) received any analgesia. 132 female patients (19%) and 83 male patients (20%) received opioid analgesia. In multivariate analyses, female patients were equally likely to receive any analgesia (OR 1.30, 95% CI 0.97–1.74, p ​= ​0.07), but time to analgesia was 14% longer (GMR 1.14, 95% CI 1.00–1.29, p ​= ​0.04). Non-White patients were 32% less likely to receive opioids (OR 0.68, 95% CI 0.47–0.97, p ​= ​0.04).

Conclusions

Female pediatric ED patients were equally likely to receive any analgesia as male patients, but their time to analgesia was longer. Non-White patients were less likely to receive opioid analgesia than White patients.

Background

Operative hysteroscopy intravascular absorption syndrome is a little-known disease traditionally caused by the use of a hypo-osmolar distension fluid during hysteroscopic surgery. Symptoms of OHIA syndrome include pulmonary and cerebral edema, hyponatremia, and metabolic acidosis. Preventive measures include the use of a bipolar current, NaCl 0.9 ​%, and limiting positive fluid balance to 1000 ml.

Case report

This paper describes the curious case of a middle-aged patient who presented to our emergency department with eye congestion, anasarca, and pulmonary edema following hysteroscopy, despite using NaCl 0.9 ​% as a distension fluid. Only a few cases have been reported in the literature, and it appears that the use of glycine instead of NaCl 0.9 ​% does not lead to the same complications. To better handle these situations, this article provides treatment suggestions and preventive measures through a literature review to help physicians to rapidly detect and manage this potentially life-threatening syndrome.

Why Should an Emergency Physician Be Aware of This ? - OHIA syndrome can be life-threatening and may manifest with various complications, requiring different management approaches and complementary examinations depending on the distension fluid used by the surgeon. Physicians should be knowledgeable about this lesser-known syndrome in order to effectively prevent, diagnose, and treat it.

Background

Slow ventricular tachycardia (VT) can be difficult to diagnose on electrocardiogram given its atypical rate of less than 120 beats per minute. In patients with implanted defibrillators, slow VT can be overlooked and have detrimental consequences for patients given their decreased cardiac output. In this case, slow VT was identified early, and was caused by an overdose of amiodarone.

Case report

A 50-year-old male with an extensive past medical history of polysubstance abuse and heart failure with implanted defibrillator (AICD) presented with a suspected heroin overdose, along with cocaine use, and acute overdose of 20–25 200 mg amiodarone tablets over 48 hours. The patient was found to be in a slow, wide-complex rhythm, and after hyperkalemia was ruled out, electrophysiology was contacted, and they diagnosed the patient with slow VT. This was corrected with overdriving pacing, and the patient was discharge home after a brief admission.

Why should an emergency physician be aware of this

There are currently no case reports showing an isolated amiodarone overdose causing slow VT, and while cocaine can cause VT due to its sodium channel blocking effects, the slow rate suggests the amiodarone overdose influenced the cardiac myocytes. This patient was predisposed to developing episodes of VT due to his underlying cardiac conditions and substance use, but had no evidence of slow VT prior to his acute amiodarone overdose. We recommend all providers be aware of the potential arrhythmic complications of isolated amiodarone overdoses, and specifically the management of slow VT, with overdrive pacing as opposed to cardioversion potentially having more success.

Background

Infectious mononucleosis (IM) caused by Epstein-Barr virus typically presents with fever, pharyngitis, and lymphadenopathy, and most patients recover within a few weeks. However, bilateral peritonsillar abscess is a rare but serious complication of IM that can lead to airway compromise and descending mediastinitis. Due to its rarity and similarity in clinical presentation of IM, it may be challenging to diagnose bilateral peritonsillar abscess during the course of IM.

Case report

A 21-year-old healthy male who initially presented with fever, sore throat, and abdominal discomfort for ten days was diagnosed with IM based on clinical and laboratory findings. Despite initial treatment, the patient returned to the emergency department three times within one week due to persistent symptoms, and on the third visit, he had difficulty opening his mouth and had worsening odynophagia. Contrast-enhanced computed tomography revealed bilateral peritonsillar abscess, and an emergent incision of the right tonsil was performed. Bacterial culture revealed multiple oral organisms. He was diagnosed with bilateral peritonsillar abscess associated with IM and was discharged without complications.

Why should an emergency physician be aware of this?

This case highlights two important clinical issues: the potential for patients with IM to develop bilateral peritonsillar abscess and the significance of trismus and exacerbation of odynophagia as a clue for identifying this complication. The rarity of this complication may result in delayed diagnosis and treatment, leading to serious complications. Prompt diagnosis and treatment are crucial for preventing potentially life-threatening consequences.

Background

Bupivacaine, an amide local anesthetic, is commonly used in intrathecal pumps (IT) for pain and spasticity disorders. Pump malfunctions place patients at risk of bupivacaine overdose and local anesthetic systemic toxicity (LAST); however, there are limited reports of this in the literature.

Case report

A 24-year-old male with an IT bupivacaine/baclofen pump presented with weakness, numbness, dyspnea, and somnolence secondary to IT pump malfunction with an unknown amount of bupivacaine/baclofen extravasation into the subcutaneous space. The patient required intubation and vasopressor support but remained persistently hypotensive and bradycardic despite aggressive dose titration. Needle aspiration was performed to remove 14 mL of extravasated drug mixture. Due to persistent hemodynamic instability, intravenous lipid emulsion (ILE) therapy was initiated with 20 ​% lipid emulsion 1.5 mL/kg bolus followed by a continuous infusion of 0.25 mL/kg/min. The patient became hemodynamically stable following 750mL of ILE therapy and was admitted to the intensive care unit. Five hours after ILE therapy cessation, the patient again became hemodynamically unstable, and ILE was re-initiated with a bolus and continuous infusion. Sustained hemodynamic stability was achieved after an additional 450mL of ILE.

Why should an emergency physician be aware of this?

IT pump malfunction involving bupivacaine can lead to severe LAST necessitating ILE therapy. Clinicians should be aware of the potential for drug deposition leading to prolonged or recurrent hemodynamic instability requiring repeated administration of ILE therapy.

Background

Airbags are a life-saving apparatus for patients involved in motor vehicle collisions (MVC). However, part of that apparatus includes the presence of alkaline chemicals that can induce ocular injury. Traumatic eye injuries are well documented in the literature in the setting of MVCs, yet ocular alkali burns are under-recognized and a dearth of case reports exists.

Case report

A 26-year-old male presented following an MVC complaining of severe unilateral eye pain in the setting of direct airbag related trauma. Ocular pH testing later revealed an alkaline injury of the right eye. Ocular irrigation was initiated in the emergency department until the pH reached normal levels.

Why should an emergency physician be aware of this?

Recognition of airbag-associated alkaline chemical burns of the eye in the setting of an MVC and appropriate management are imperative to avoid deleterious outcomes such as permanent vision loss.