JEM reports最新文献

Background

Burnout, mental health issues, and sleep disorders continue to be a problem among emergency medicine physicians, affecting patient care, personal well-being, and retention of the specialty.

Case report

A 35-year-old female emergency medicine intern is brought in by her assistant program directors for altered mental status and ataxia, concerning for alcohol or drug intoxication. It was noted that she was confused, oriented only to self, and seemed to be experiencing auditory hallucinations. Also noted was she was tremulous and exhibited an ataxic gait. However, lab testing was inconsistent with drug or alcohol intoxication. During her hospital admission, it was discovered she had been awake over 80 hours after gaining collateral from friends and family. With the administration of a large amount of trazodone, she eventually fell asleep and was later diagnosed with four different sleep disorders and successfully treated by sleep specialists. This case is discussed here to bring more awareness to the poor state of wellness in the emergency medicine specialty and to suggest practical ways to address these multifactorial issues.

Background

Acute epiglottitis is a life-threatening condition usually caused by streptococcal or staphylococcal species. It is rarely caused by Pasteurella multocida, which is an oropharyngeal commensal in cats and dogs, and is usually responsible for human skin infections following inoculation by bite or scratch.

Case report

We report a case of a 50-year-old female who presented to the emergency department with acute epiglottitis due to Pasteurella multocida. The patient suffered rapid deterioration and subsequent hypoxic cardiac arrest requiring advanced life support measures and intubation. She recovered well following a course of penicillin-based intravenous antibiotics and airway support in the intensive care unit. Infection was likely acquired after close contact with her pet dog.

Why an emergency physician should be aware of this

Pasteurella multocida can cause a variety of atypical infections, including acute epiglottitis, and should be considered a possible causal organism in those with a history of animal exposure. While it is important to take a careful exposure history, the nature of a patient's presentation may necessitate a reliance on collateral history when there is unexpected and rapid patient deterioration. As is demonstrated in this case, the diagnosis, management, and treatment of adult-onset epiglottitis is multidisciplinary in nature and reliant on careful patient assessment that correlates pertinent historical findings with relevant laboratory results.

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.