Nova L. Panebianco, Frances Shofer, J. Matthew Fields, Kenton Anderson, Alessandro Mangili, Asako C. Matsuura, Anthony J. Dean
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.023
Published online: February 20 2015
xFor patients with early intrauterine pregnancy (IUP), the sonographic signs of the gestation may be below the resolution of transabdominal ultrasound (TAU); however, it may be identified by transvaginal ultrasound (TVU). We sought to determine how often TVU performed in the emergency department (ED) reveals a viable IUP after a nondiagnostic ED TAU and the impact of ED TVU on patient length of stay (LOS).
Mehmet Kaynar, Ferudun Koyuncu, İbrahim Buldu, Erdem Tekinarslan, Abdulkadir Tepeler, Tuna Karatağ, Mustafa Okan İstanbulluoğlu, Kadir Ceylan
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.033
Published online: February 25 2015
xThe objective is to compare the analgesic effects of diclofenac, acetaminophen, and acupuncture in urolithiasis-driven renal colic pain relief.
Jingxiang Zhao, Guocheng Pan, Bo Wang, Yuhua Zhang, Guoxing You, Ying Wang, Dawei Gao, Hong Zhou, Lian Zhao
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.041
Published online: February 26 2015
xWe aimed to evaluate the effects of resuscitation with different ratios of fresh frozen plasma (FFP) to red blood cells (RBCs) on pulmonary inflammatory injury and to illuminate the beneficial effects of FFP on lung protection compared with lactated ringers (LR) using a rat model of hemorrhagic shock.
Jianqiang Huang, Yanyan Chen, Zhixiong Cai, Ping Chen
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.043
Published online: March 4 2015
xThe aims of the study are to investigate the changes in platelet indexes, including platelet count, platelet distribution width (PDW), and mean platelet volume (MPV), in patients with pulmonary embolism (PE) and to evaluate their diagnostic values in relation to this disease.
William D. Spector, Rhona Limcangco, Ryan L. Mutter, Jesse M. Pines, Pamela Owens
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.045
Published online: March 6 2015
xInpatient hospital costs represent nearly a third of heath care spending. The proportion of inpatients visits that originate in the emergency department (ED) has been growing, approaching half of all inpatient admissions. Injury is the most common reason for adult ED visits, representing nearly one-quarter of all ED visits.
Andrea F. Dugas, Alexandra Valsamakis, Mihir R. Atreya, Komal Thind, Peter Alarcon Manchego, Annum Faisal, Charlotte A. Gaydos, Richard E. Rothman
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.008
Published online: March 14 2015
xTimely and accurate diagnosis of influenza remains a challenge but is critical for patients who may benefit from antiviral therapy. This study determined the test characteristics of provider diagnosis of influenza, final ED electronic medical record (EMR) diagnosis of influenza, and influenza-like illness (ILI) in patients recommended to receive antiviral treatment according to Centers for Disease Control and Prevention (CDC) guidelines. In addition, we evaluated the compliance with CDC antiviral guidelines.
Adam J. Singer, Justin Williams, Maria Taylor, Deborah Le Blanc, Henry C. Thode Jr.
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.034
Published online: March 19 2015
xWe determined the effects of comprehensive point-of-care testing (POCT) on process of care in critically ill emergency department (ED) patients. We hypothesized that POCT would shorten ED length of stay (LOS), reduce time to test results, and reduce time to completion of intravenous (IV) contrast computed tomography (CT) imaging compared with central lab testing.
Matthew W. McAllister, Patrick Aaronson, Joe Spillane, Mark Schreiber, Genelyn Baroso, Dale Kraemer, Carmen Smotherman, Kelly Gray-Eurom
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.036
Published online: March 19 2015
xIn 2009, Florida initiated a statewide prescription drug-monitoring program (PDMP) to encourage safer prescribing of controlled substances and reduce drug abuse and diversion. Data supporting the utility of such programs in the emergency department (ED) is scarce. This study sought to determine the effect of PDMP data on controlled substance prescribing from the ED.
Lauren R. Klein, Gautam R. Shroff, William Beeman, Stephen W. Smith
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.044
Published online: March 27 2015
xST elevation (STE) on the electrocardiogram (ECG) may be due to acute myocardial infarction (AMI) or other nonischemic pathologies such as left ventricular aneurysm (LVA). The objective of this study was to validate 2 previously derived ECG rules to distinguish AMI from LVA. The first rule states that if the sum of T-wave amplitudes in leads V1 to V4 divided by the sum of QRS amplitudes in leads V1 to V4 is greater than 0.22, then acute ST-segment elevation MI is predicted. The second rule states that if any 1 lead (V1-V4) has a T-wave amplitude to QRS amplitude ratio greater than or equal to 0.36, then acute ST-segment elevation MI is predicted.
Travis Deaton, Jonathan D. Auten, Michael A. Darracq
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.046
Published online: March 25 2015
xPatients with acute abdominal pain commonly present to emergency departments. The safe and effective relief of discomfort is a concern to patients and physicians. Intravenous opioids are the traditional method used to provide pain relief in this setting, but intravenous access is time consuming and not always achievable. Alternative methods of pain control may therefore be necessary for the acute management of painful conditions without adding to the overall physical or psychological discomfort.
Jonathan Charbit, Ingrid Millet, Camille Maury, Benjamin Conte, Jean-Paul Roustan, Patrice Taourel, Xavier Capdevila
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.057
Published online: April 6 2015
xOccult pneumothoraces (PTXs), which are not visible on chest x-ray, may progress to tension PTX. The aim of study was to establish the prevalence of large occult PTXs upon admission of patients with severe blunt trauma, according to prehospital mechanical ventilation.
Catherine M. Wares, Alan C. Heffner, Shana L. Ward, David A. Pearson
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.033
Published online: February 26 2015
xTherapeutic hypothermia (TH) improves patient survival with good neurologic outcome after cardiac arrest. The value of early clinician prognostication in the emergency department (ED) has not been studied in this patient population.
Nikolas A. Collins, George L. Higgins III
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.047
Published online: March 6 2015
xThe objectives of our investigation were to review the evidence for the efficacy and safety of carotid sinus massage in terminating supraventricular tachycardia and to determine if other potentially less harmful interventions have been established to be safer and more effective.
Kevin R. Weaver, Gavin C. Barr Jr., Kayla R. Long, Leonel Diaz Jr., Aaron S. Ratner, Jeffery P. Reboul, Douglas A. Sturm, Marna Rayl Greenberg, Stephen W. Dusza, Bernadette Glenn-Porter, Bryan G. Kane
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.051
Published online: March 6 2015
xWe set out to compare emergency medicine residents’ intubating times and success rates for direct laryngoscopy (DL), GlideScope-assisted intubation (GS), and the Supraglottic Airway Laryngopharyngeal Tube (SALT) airway with and without biohazard gear.
Eric Scheier, Chen Gadot, Ronit Leiba, Itai Shavit
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.033
Published online: March 19 2015
xLiterature to date has suggested advantages of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. However, there is a paucity of data regarding sedation with the combination of ketamine and propofol in pediatric emergency medicine.
Yuko Nakajima, Gary M. Vilke
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.005
Published online: March 10 2015
xAs the ultimate safety net, emergency departments (EDs) are expected to care for any patient, at any time, under any circumstances. When EDs are overwhelmed in periods of surge, one solution is to redistribute patients. A commonly used method for redistributing patients is ambulance diversion. Ambulance diversion is not a new phenomenon and, over time, has become commonly used by EDs to address the growing problem of ED overcrowding and saturation [1]. As ED visits have increased through the years, ambulance diversion has evolved into standard practice in many health systems.
Eric J. Adkins, Howard A. Werman
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.007
Published online: March 14 2015
xAmbulance diversion presents a dilemma pitting the ethical principles of patient autonomy and beneficence against the principles of justice and nonmaleficence. The guiding priority in requesting ambulance diversion is to maintain the safety of all patients in the emergency department as well as those waiting to be seen. Policies and procedures can be developed that maintain the best possible outcome for patients transported by ambulance during periods of diversion. More importantly, the discussion must focus on addressing the operational inefficiencies within our health systems that lead to conditions such as patient boarding, high waiting room congestion, and ambulance diversion.
Joel M. Geiderman, Catherine A. Marco, John C. Moskop, James Adams, Arthur R. Derse
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.002
Published online: December 9 2014
xAmbulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. Other responses to this mismatch include maladaptive behaviors (such as “boarding” in “hallway beds”) and the development of terminology intended to normalize these practices, all of which are reviewed in this article.
Michael E. Winters, Joseph P. Martinez, Haney Mallemat, William J. Brady
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.049
Published online: March 25 2015
xIn recent years, the annual number of hours of critical care provided in emergency departments (EDs) has increased dramatically [1]. In addition to increases in the number of ED patients admitted to an intensive care unit (ICU), it is clear that critically ill patients are staying longer in the ED. In fact, more than 33% of critically ill patients now remain in the ED for more than 6 hours [1]. Emergency physicians (EPs) are the first clinicians to resuscitate and manage critically ill patients, so it is imperative for them to be knowledgeable regarding recent advances in critical care.
Frank LoVecchio, Olivia Zoph
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.036
Published online: February 25 2015
xElectronic cigarettes, also known as e-cigarettes or e-cigs, are nicotine delivery systems that consist of a rechargeable battery, atomization chamber, and a cartridge containing a solution of nicotine, flavor, and other chemicals. E-cigarette health effects remain largely unknown, and there are mixed reports on the efficacy of electronic cigarettes in smoking cessation [1].
Lovely Chhabra, Vinod K. Chaubey
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.038
Published online: February 26 2015
xWe read with great pleasure the interesting report by Aiman et al [1]. The proposed hypothesis of vasospasm of isolated right-sided coronary arteries is appealing and well possible; however, other relevant considerations should be entertained especially in the absence of objective evidence of vasospasm during coronary angiography. Because the patient was unresponsive, hypotensive, and acidotic, concomitant significant hypoxia is presumably highly likely. Patients with hypoxic respiratory failure or even drug overdose can manifest as transient right ventricular dysfunction and also frequently with biventricular dysfunction [2].
Aiman Smer, Toufik Mahfood Haddad, Venkata Alla
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.037
Published online: February 26 2015
xWe thank Dr Chaubey for his interest in our report and appreciate his thoughtful comments [1]. He raised 2 relevant questions: (1) could this be a variant of stress cardiomyopathy or a rare case of isolated right ventricular (RV) stress cardiomyopathy? and (2) could the current presentation be due to acute RV failure from hypoxia- and cocaine-induced pulmonary vasoconstriction.
Carlos Henrique Miranda, Maria Fernanda Braggion-Santos, André Schmidt, Antônio Pazin Filho, Palmira Cupo
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.039
Published online: February 26 2015
xRegarding the suggestion performed by this correspondence, we analyze the voltage of the QRS complex in the limb and precordial leads in the available electrocardiogram (ECG) recorded during the evolution of this case published online ahead of print on December 30, 2014, in this Journal [1]. This case described a 7-year-old boy who developed a myocardial involvement similar to a stress-induced cardiomyopathy (Takotsubo), triggered by scorpion envenomation. We reported the cardiac magnetic resonance findings demonstrating transient edema in the apical region of the left ventricle.
John E. Madias
DOI: http://dx.doi.org/10.1016/j.ajem.2015.02.040
Published online: February 28 2015
xThe case report by Miranda et al [1], published online ahead of print on December 30, 2014, in the Journal, about a 7-year-old boy who suffered Takotsubo syndrome (TTS) triggered by scorpion envenomation includes a set of 2 interesting electrocardiograms (ECGs) worth commenting on: (1) ECG A of Fig. 1 reveals excessive ST-segment elevation (+ST) in V2, which rarely is encountered in TTS but is occasionally seen in the setting of hyperacute +ST myocardial infarction, characterized by merging of the +ST with the QRS complex, resembling intraventricular conduction delay, and attributed to slow intraventricular conduction [2].
Sevket Balta, Sait Demırkol, Murat Unlu, Cengiz Ozturk, Zekeriya Arslan, Mustafa Demır
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.004
Published online: March 6 2015
xWe have read the recently published article entitled “Electrocardiographic abnormalities in patients with acute pulmonary embolism (APE) complicated by cardiogenic shock (CS)” by Kukla and coworkers [1]. In that very well-designed and presented study, Kukla and coworkers tried to compare electrocardiographic (ECG) parameters in patients with APE presenting with or without CS. They have concluded that, in patients with APE, low QRS voltage, right bundle-branch block (RBBB), and ST-segment elevation in lead V1 were associated with CS.
Jyotindu Debnath, R. Ravikumar, C.G. Muralidharan, Giriraj Singh
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.010
Published online: March 14 2015
xWe read with interest the article titled “Alvarado score: can it reduce unnecessary computed tomographic (CT) scans for evaluation of acute appendicitis (AA)?” written by Apisarnthanarak et al and published online ahead of print in the Am J Emerg Med 2014 [1]. We find the article interesting on several accounts as detailed below.
Piyaporn Apisarnthanarak, Linda M. Mundy, Anucha Apisarnthanarak
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.009
Published online: March 14 2015
xThank you for your interest in our article entitled “Alvarado score: can it reduce unnecessary computed tomography (CT) for evaluation of acute appendicitis? [1].” Your suggestion about the role of ultrasound in the diagnosis of acute appendicitis is valuable. We do agree that ultrasound and CT scan share their important roles in the diagnosis of acute appendicitis. This issue has been discussed and compared thoroughly in many studies [2-8]. Definitely, ultrasound is less invasive due to lack of ionizing radiation and intravenous (IV) contrast.
Daniel J. Reschke, Zachary H. Seeskin, Elizabeth A. Hahn, Peter S. Pang
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.011
Published online: March 15 2015
xWe agree with the letter by Fukui et al [1] that Shared Decision Making (SDM) is important in the care of all patients, including those with psychologic complaints. In fact, a number of factors and situations affect patient preferences for SDM, including acuity, severity of disease, ethnicity of patients, socioeconomic status, and the type of care delivered [2-6].
Vinod K. Chaubey, Nirmal J. Kaur
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.012
Published online: March 15 2015
xWe read with great pleasure the work by Reschke et al [1]. The authors have done commendable work in emphasizing the significance of shared decision making (SDM) in improving patient satisfaction and reducing health care cost [2]. In spite of its inherent challenges, SDM is rightly being increasingly implemented in the emergency department (ED) resulting in enhanced patient-centric care [3]. Although the burden of shared effective decision making in terms of options, risks, and benefits may appear challenging in an individual with psychologic complaints, SDM has become important in establishing the long-term goal of care in these subgroup of patients as well.
Catarina Félix, Nádia Fernandes, Miguel Milheiro, André Florêncio, Hipólito Nzwalo
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.013
Published online: March 17 2015
xLiao et al [1] presented a case of hypertensive brain stem encephalopathy (HBSE), a rarely reported central variant of posterior reversible encephalopathy syndrome. We would like to acknowledge the authors for the diagnosis and concise discussion. The authors also highlighted the possibility of misdiagnosis of this entity. We have diagnosed 3 cases of HBSE in our institution in the last year. Our cases were remarkably similar in their clinical and radiologic presentation, with patients observed for the first time in the emergency department because of headache in the context of acute severe elevation of blood pressure (values >170/100 mm Hg in all).
Jean-Pierre Tourtier, Patrick Pelloux, Pascal Dang Minh, Isabelle Klein, Jean-Sébastien Marx, Pierre Carli
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.026
Published online: March 15 2015
xThe events that shocked France and transfixed the rest of the world began in the editorial room of the satirical magazine Charlie Hebdo. Two terrorists forced their way into the meeting room and opened fire with Kalachnikov rifles. Another columnist, who is also an emergency physician of Paris SAMU, was still at a meeting with firefighters and emergency medical services leaders to discuss how to improve hospital admission services about 600 meters away when his mobile phone rang. It was one of survivors: “Come fast, we need you at Charlie.” He rode by motorcycle with the chief physician of the Paris fire department toward the crime scene.
Joseph Stone, David Cheng
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.029
Published online: March 19 2015
xAs news broke of a Dallas Presbyterian Hospital nurse positive for the Ebola virus, the West African hemorrhagic fever, on October 15, 2014, who had visited the Cleveland-Akron area on October 13 to 14, media outlets and the public reacted with panic and speculation. Hospital administration and emergency department (ED) leaders quickly enacted preparatory protocols and public educational outreach measures. Efforts were made to quickly stem anxiety of hospital staff through both education and preparation, including brisk outreach to the public with local news coverage and public education of the disease, daily intrafacility newsletter e-mails, isolation protocols, and increased patient screening.
Frank Lovecchio, C. William Heise
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.030
Published online: March 24 2015
xMany states have passed laws legalizing medical marijuana. The Arizona Medical Marijuana Act was enacted on November 2, 2010, by 50.13% of voters. The state’s first dispensary opened in December of 2012. Patients are able to have up to 2.5 oz of useable marijuana from a dispensary or up to 12 plants for personal use if they live more than 25 miles from the nearest dispensary.
Getaw Worku Hassen, Asha A. Roy, Ivan Becerra, Monica Diep, Ioana Scherbakova, Lara DeNonno, Roger Chirurgi, Peter McCorkell, Andrea Bulbena-Cabre, Norma Dunn
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.037
Published online: March 19 2015
xThere is an ongoing rise in use of synthetic cannabinoids (SC) with various clinical and psychiatric symptoms [1-4]. These products come in different flavors, and the presenting symptoms vary with each type of K2 ranging from agitation, altered mental status, lethargy, paranoid behavior, psychosis, and seizures. K2 is legally marketed and sold as incense and potpourri and is produced with common herbal products mixed with synthetic cannabis [1,5-8]. The SC compounds are sprayed over various herbal plants, some of which also have intrinsic psychotropic effects, and the combination produces different clinical and psychiatric symptoms.
Heidi Riha, Patrick Aaronson, Andrew Schmidt
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.045
Published online: March 25 2015
xEffectively managing pain is known to be problematic in the emergency department (ED) with up to 43% of patients with oligoanalgesia [1–3]. Opioids alone are commonly inadequate at controlling acute and acute on chronic pain in the ED [4–6]. Furthermore, using higher doses or more potent opioids may be challenging in some patients because of the risk of adverse effects such as somnolence, respiratory and hemodynamic depression, nausea, and vomiting [7–12].
Anup Katyal, Dayton Dmello, Robert W. Taylor
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.053
Published online: March 25 2015
xWe read with avid interest the article “Evidence-based diagnosis and thrombolytic treatment of cardiac arrest or periarrest due to suspected pulmonary embolism” as recently published by Logan et al [1]. We wish to concur with the authors in recognizing that thrombolytic administration for massive pulmonary embolism (PE) as a cause of cardiac arrest is a well-recognized but often overlooked therapeutic strategy in clinical practice and also recognize the clinical uncertainty involving the dosing regimen of thrombolytic therapy in this clinical scenario.
Mahmut Yesin, Macit Kalçık, Süleyman Karakoyun, Mehmet Ali Astarcıoğlu, Mustafa Ozan Gürsoy, Sabahattin Gündüz, Mehmet Özkan
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.055
Published online: March 31 2015
xWe would like to comment on the recent article reported by Saha et al [1] that was recently published in the American Journal of Emergency Medicine. Thanks to the authors for their contribution of the present report describing thrombolytic therapy (TT) with streptokinase (SK) in a pregnant patient with prosthetic valve thrombosis (PVT). However, we feel that there remain some drawbacks to be addressed regarding the patient management and TT regimens for PVT in pregnancy.
Bharti Joshi
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.056
Published online: March 31 2015
xThrombotic occlusion of prosthetic valve during pregnancy is uncommon but one of the dreadful complication with unclear management strategies. In general, conservative approach, re-replacement surgery, thrombectomy, and thrombolytic therapy are the accepted treatment modalities for prosthetic valve thrombosis (PVT) with their own pros and cons. Treatment modalities should be customized based upon clinical status, valve location, comorbidities, and informed decision [1]. Conservative approach is suitable for stable patients or when there is any contraindication for surgery or thrombolytic therapy.
Stuart E. Greene, Richard Massone
DOI: http://dx.doi.org/10.1016/j.ajem.2015.03.067
Published online: April 6 2015
xMany initiatives have been proposed to reduce health care expenditures in the United States because of the continued rise in medical care costs. The Choosing Wisely campaign has been developed by physicians and for physicians; and its primary aim is to provide care that is “supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary” [1]. Through guidelines, it is the hope that Choosing Wisely will reduce unnecessary testing and treatment, thereby reducing wasteful spending and potential harm to patients.
Sema Avcı, Fatih Büyükcam, Ömer Faruk Demir, Seda Özkan
DOI: http://dx.doi.org/10.1016/j.ajem.2014.11.041
Published online: December 1 2014
xOzone (O3) gas is a molecule that consists of 3 oxygen atoms, found out in the mid-19th century [1]. Ozone gas preserves humans from detrimental influences of ultraviolet radiation [1]. In spite of harmful effects of O3 gas, investigators think that it has excessive curative effects [1]. Nowadays, O3 therapy is used for many fields of medicine in precise therapeutic doses [1,2]. It is known that O3 therapy is helpful in dental procedures, cerebrovascular diseases, tinnitus, acquired immunodeficiency syndrome, hypercholesterolemia, sensorial hypoacusis, senile dementia, multiple sclerosis, irradiation sensitive tumors, herpes simplex and herpes zoster virus infections, muscular hypertonia, and chronic otitis media, etc.
Richard F. Clark, Charles W. O’Connell, Janna H. Villano, Andrew Kim, Binh T. Ly, Alicia B. Minns
DOI: http://dx.doi.org/10.1016/j.ajem.2014.11.047
Published online: December 2 2014
xIntroduction: Effects in crotaline snake envenomation include tissue destruction and hemotoxicity. The only available antivenom for treatment in this country is Crotalidae Polyvalent Immune Fab (CPIF) ([Ovine] CroFab; BTG, West Conshohocken, PA). Recurrence is a delayed appearance of coagulopathy and other symptoms in envenomated individuals after stabilization with CPIF. When recurrence was first observed, treatment protocols added extra or “maintenance” doses of antivenom in an attempt to decrease the rate of recurrent symptoms.
Catherine Ginty, Adarsh Srivastava, Michael Rosenbloom, Sally Fowler, Lisa Filippone
DOI: http://dx.doi.org/10.1016/j.ajem.2014.11.045
Published online: December 2 2014
xOn average, approximately 1300 Americans die of hypothermia each year [1]. Although accidental hypothermia is commonly associated with severely cold regions or mountain accident victims, hypothermia also commonly occurs in urban centers. Contributing factors often include homelessness, mental illness, and substance abuse [2]. Hypothermia can profoundly affect the cardiovascular system. As the myocardium cools, the conduction system slows down, which results in prolongation of the QT interval as well as propensity for arrhythmias.
C. Galland, B. Sergent, C. Pichot, M. Ghignone, L. Quintin
DOI: http://dx.doi.org/10.1016/j.ajem.2014.11.053
Published online: December 4 2014
xA male patient presented with bronchospasm and acute respiratory distress. The patient had presented 2 previous episodes of severe bronchospasm following abdominal surgery, leading twice to intubation, mechanical ventilation, and conventional sedation. As the patient positively rejected a third episode of intubation + mechanical ventilation, noninvasive ventilation (pressure support = 8 cm H20, positive end-expiratory pressure = 10 cm H20), inhaled therapy, and clonidine orally (≈4 μg/kg) were combined.
Anis Chaari, Kamilia Chtara, Nozha Toumi, Mabrouk Bahloul, Mounir Bouaziz
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.009
Published online: December 18 2014
xNeurogenic pulmonary edema (NPE) is a possible complication of severe central nervous system insult. Its physiopathology is still debated. We report a fatal case of a 55-year-old man who was admitted because of severe head injury. The diagnosis of NPE was considered according to clinical and radiologic findings. Transpulmonary thermodilution study showed decreased stroke volume index and cardiac function index. Indexed extravascular lung water was increased as well as pulmonary vascular permeability index.
Christopher Beynon, Anna Potzy, Andreas W. Unterberg, Oliver W. Sakowitz
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.017
Published online: December 18 2014
xA debate has emerged regarding the safety profile of direct anticoagulants, which are increasingly prescribed for the prevention of thromboembolic events. Despite favorable safety data derived from controlled clinical trials, the absence of specific antidotes for the management of hemorrhagic complications represents a major challenge for emergency physicians. Here, we present the first report on patients treated with the direct factor Xa inhibitor apixaban and conditions requiring urgent neurosurgical intervention (intracerebral hemorrhage, n = 1; subdural hematoma, n = 1).
Mariko Obinata, Kouhei Ishikawa, Hiromichi Osaka, Kentaro Mishima, Kazuhiko Omori, Yasumasa Oode, Youichi Yanagawa
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.027
Published online: December 19 2014
xA 44-year-old man who drove a motorcycle experienced a collision with the side of another motorcycle. Because he had sustained a high-energy injury to the spinal cord, he was transferred to our hospital. His circulation was unstable, and received tracheal intubation in addition to thoracostomy for the hemothorax. Whole-body computed tomography (CT) revealed multiple fractures, right hemopneumothorax with pulmonary contusion, and minor liver injury. After infusing 5000 mL of lactated Ringer’s solution and 10 units of blood, his circulation remained unstable.
Athanasios Papathanasiou, Vasiliki Zouvelou, David P. Breen, Timothy J. Phillips, Anjum Misbahuddin, Sanjiv Chawda, Rajith de Silva
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.026
Published online: December 19 2014
xThunderclap headache is a common emergency department presentation. Although subarachnoid hemorrhage (SAH) should be the first diagnosis to exclude, reversible cerebral vasoconstriction syndrome (RCVS) is an important alternative cause, which may be commoner than appreciated. Reversible cerebral vasoconstriction syndrome is characterized by multifocal narrowing of cerebral arteries, typically manifested by acute, severe headache with or without neurologic deficits.
Getaw Worku Hassen, Brett Sweeney, Tania Portillo, Dinah Ali, Omer Nazeer, Rania Habal, Miguel Arbulu, Roger Chirurgi, David Toro, Hossein Kalantari
DOI: http://dx.doi.org/10.1016/j.ajem.2014.11.042
Published online: December 1 2014
xIncreased anterior chamber pressure also known as intraocular pressure can result from conditions such as glaucoma and trauma. The pressure in the anterior chamber is measured using tonometer. Measurement of the intraocular pressure is essential, as it requires immediate medical attention to alleviate pain and to avoid temporary or permanent damage to intraocular structures. Bedside ocular ultrasound (US) has gained popularity in recent years. It has been used to assess intracranial pressure via optic nerve sheath diameter (ONSD) and evaluate retinal detachment, vitreous hemorrhage, or pupillary reflex in a trauma patient.
Jennifer Singleton, Alon Dagan, Jonathan A. Edlow, Beatrice Hoffmann
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.030
Published online: December 19 2014
xIdiopathic intracranial hypertension (IIH), also referred to as pseudotumor cerebri, is a condition of raised intracranial pressure (ICP) with unknown etiology. Sonographic measurement of optic nerve sheath diameter (ONSD) has been shown to be a reliable, noninvasive method to characterize elevated ICP in a variety of settings. However, little is known about the immediate response of ONSD to an acute reduction in ICP after lumbar puncture. We describe a case of an emergency department patient with IIH in whom we identified real-time change in ONSD correlated with a decrease in cerebrospinal fluid pressure after a therapeutic lumbar puncture.
Hasan Kara, Murat Akinci, Selim Degirmenci, Aysegul Bayir, Ahmet Ak
DOI: http://dx.doi.org/10.1016/j.ajem.2014.12.040
Published online: December 26 2014
xThe presence of air in the spinal canal is known as pneumorrhachis (PNR), aerorachia, intraspinal pneumocele, pneumosaccus, pneumomyelogra, or intraspinal air. Pneumorrhachis may be iatrogenic, traumatic, and nontraumatic. We treated 2 patients who had posttraumatic PNR in the cervical spine region after stab injuries. Case 1 was a 31-year-old man who was stabbed in the C5 to C6 region. He had muscle weakness (3/5) and numbness on the right side of the body. Brain computed tomographic (CT) scan showed pneumocephalus, and cervical CT scan showed PNR at the C6 level.
