查看更多>>摘要：? 2021 Elsevier Inc.Background: Flecainide is a commonly used IC antiarrhythmic. Clinical presentations of Flecainide toxicity are not commonly described. Case report: A 62 year old man on dialysis presented for evaluation of outpatient bradycardia and hypotension. In the ED, patient had wide-complex rhythm with heart rates ranging from 76 to 127. The previous day, Flecainide and Metoprolol were discontinued and patient was dialyzed and discharged. The patient was treated empirically for possible hyperkalemia. No significant change in ECG was noted with administration of calcium. Sodium bicarbonate produced questionable benefit. Potassium level was 4.6 mmol/L. Cardiac rhythm fluctuated between sinus rhythm and wide complex tachycardia in the ED & ICU. Flecainide level was 2.1 μg/ml (normal <1 μg/ml). Toxicity developed despite previous discontinuation and dialysis prior to presentation because of Flecainide's large volume of distribution and lipopholicity. Why should an emergency physician be aware of this?: Although Flecainide toxicity is uncommon, it has a high mortality rate, requiring early identification and treatment. Flecainide toxicity can develop in patients with hepatic or renal insufficiency, and can manifest with ventricular tachycardia or bradycardia. If suspicion of Flecainide toxicity arises, lidocaine and procainamide should be avoided to prevent further sodium channel blockade. Absence of response to calcium for a very wide complex QRS should raise clinicians' suspicion that WCT is not due to hyperkalemia, emphasizing the importance of reviewing patients' home medications. Sodium bicarbonate should be administered early to treat widened QRS. Amiodarone, intralipid emulsion therapy and ECMO may be considered in severe cases.
查看更多>>摘要：? 2021 Elsevier Inc.Being considered among the most fatal neurological conditions, Creutzfeldt-Jakob disease is a transmissible spongiform encephalopathy characterized by its unknown etiology and rapidly progressive neurodegenerative symptoms that often lead to a mean survival of 6 to 12 months. The accumulation of the prionic protein causes brain matter degeneration, which leads to a set of clinical findings that include rapidly progressive dementia, myoclonus, tremors, cerebellar ataxia, and extrapyramidal signs. This clinical presentation is non-specific, which makes CJD a very difficult condition to diagnose, due to the low level of clinical suspicion. However, combining this clinical presentation with neuroimaging, a lumbar puncture and an encephalogram will help us make the correct diagnosis. We present the case of a 57-year-old male presenting to the Emergency department with complaint of personality change and intermittent memory loss. The patient's physical exam was significant for resting pill roll tremor, bilateral cogwheel rigidity, dysmetria, and shuffling gait. Magnetic resonance imaging of his brain showed symmetric bilateral diffusion signal abnormality involving the cortex, bilateral caudate heads and putamina. Continuous electroencephalogram revealed multiple bifrontal delta discharges with triphasic morphology. Lumbar puncture was significant for presence of 14–3-3 protein in cerebrospinal fluid. The multiple examinations performed in conjunction with the previous findings supported the diagnosis of acute encephalopathy secondary to sporadic CJD.
查看更多>>摘要：? 2021 Elsevier Inc.This report describes a case of hemolysis in a patient injecting deoxycholic acid and benzyl alcohol for aesthetic benefit without medical supervision. The concentration and dose injected by the patient resulted in a 10-fold overdose of deoxycholic acid in comparison to the FDA-recommended dosing for the approved indication. Providers should be aware of medically unsupervised use of DCA and other injectables and the potential risks associated with this practice.
查看更多>>摘要：? 2021 Elsevier Inc.Myofascial pain affects about 10% of the United States population, often involves the trapezius muscle, and can be difficult to manage using conventional analgesic medications in the Emergency Department (ED). The use of ultrasound-guided nerve blocks performed by emergency physicians is well-documented, but this is the first report describing the technique and effectiveness of an ultrasound-guided spinal accessory nerve block for acutely treating trapezius myofascial pain in the ED setting. In this case series of three patients with intractable trapezius pain, the ultrasound-guided spinal accessory nerve block proved feasible and offered substantial therapeutic benefit.
查看更多>>摘要：? 2021Sigmoid volvulus occurs when a portion of sigmoid colon twists around its blood supply at the base of the mesentery, causing ischemia and necrosis. In developed nations, this is most commonly a condition of elderly, bed-bound, chronically constipated individuals. However, this condition may occur after blunt abdominal trauma, especially in individuals with underlying anatomic derangements from the aforementioned conditions. We present a unique case of sigmoid volvulus in a patient with no pre-existing abdominal complaints or surgical history, who sustained blunt traumatic injuries when she was struck by a motor vehicle. Prompt recognition of this deadly condition by emergency clinicians facilitated rapid surgical correction and mitigated further morbidity and mortality.
查看更多>>摘要：? 2021 Elsevier Inc.Background: Toxicity from the intentional misuse of over-the-counter (OTC) combination cold products has been widely recognized. Adolescents are most frequently involved and dextromethorphan containing products are the most popular. Desired symptoms include stimulatory effects, euphoria, hallucinations, and dissociation. Potential adverse effects include tachycardia, agitation, hyperthermia, acidosis, and coma. However, mortality is rare [ 1-3]. Co-formulated ingredients such as acetaminophen, pseudoephedrine, and antihistamines may also be present and potentiate dangerous effects. We report a case of an adolescent decedent with markedly elevated postmortem chlorpheniramine (CPA) and dextromethorphan (DXM) blood concentrations and no other identifiable cause of death.
查看更多>>摘要：? 2021 Elsevier Inc.The incidence of anticholinergic syndrome due to second generation antihistamines is infrequently reported. Largely due to their decreased affinity for central nervous system (CNS) receptors, second generation antihistamines are rarely associated with anticholinergic symptoms, though toxicity is still possible particularly when taken in excess. We report a case of a six year old boy who presented with agitation, hallucinations, fixed and dilated pupils, tachycardia, and hyperthermia consistent with anticholinergic toxicity several hours after accidental overdose of a second generation antihistamine, cetirizine. Early identification of this rare phenomenon is important not only for appropriate emergency management but also for avoidance of potentially invasive and unnecessary tests which may further increase patient morbidity.
查看更多>>摘要：? 2021 Elsevier Inc.Alcoholic ketoacidosis (AKA) lacks specific clinical presentation. The results of blood testing commonly show hemoconcentration, elevated β-hydroxybutyrate levels, and acidosis in patients with AKA. Herein, we report a case of AKA accompanied by hyperglycemia and review the related literature. Case report: AKA associated with hyperglycemia is rare, and its pathogenesis is similar to that of diabetic ketoacidosis, thereby making differentiation challenging. Accordingly, AKA is easily misdiagnosed by endocrinologists. The main symptoms of a 37-year-old female included hyperglycemia, elevated β-hydroxybutyrate levels, and metabolic acidosis. Primary clinical presentations were severe nausea and vomiting. The patient initially diagnosed with DKA were eventually confirmed as AKA, who recovered after active therapy with rehydration and correction of hyperglycemia, electrolyte imbalance, and ketosis. This study provides a reference for clinicians to reduce missed diagnosis and the misdiagnosis rates of AKA.
查看更多>>摘要：? 2021Myocardial infarctions (MI) have been reported in adults with COVID-19. Although MIs are rare in children with COVID-19, cardiac involvement is still possible. In this case report, we present an adolescent with recent COVID-19 infection who presented with an ECG initially suggestive of myocardial infarction (MI). We describe how to differentiate between myocardial infarctions and myopericarditis. A 15-year-old boy, with a history of COVID-19 infection a month prior, presented to the emergency department with fever, abdominal pain, diarrhea, and chest pain. On ECG, he was found to have focal ST-segment elevations in V3 through V6. Given the immediate concern for MI, an emergent echocardiogram was done and showed normal left ventricular systolic function with no regional dyskinesia and normal coronary artery diameters. A repeat ECG showed diffuse ST elevations in the inferior leads and T-wave inversions on V5 and V6, confirming the diagnosis of myopericarditis. In conclusion, multisystem-inflammatory syndrome in children associated with COVID-19 (MIS-C) is a new entity describing a post-infectious inflammatory response in children with prior COVID-19 exposure. Cardiac involvement can include myopericarditis. Initial ECGs may show ST-changes suggestive of MI. However, serial ECGs and echocardiograms can differentiate between MI and myocarditis/myopericarditis. Even with COVID-19, MIs are extremely rare in children, and it is important to be aware of MIS-C and its cardiac complications.
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