查看更多>>摘要：? 2022 Elsevier Inc.Background: Zinc phosphide is a highly toxic rodenticide that reacts with hydrochloric acid in the stomach to form phosphine gas. Ingestion of zinc phosphide can result in consequential toxicity even when ingested in small quantities. Clear guidelines are lacking on appropriate personal protective equipment for providers to avoid additional exposure. Case presentation: We present the case of a four-year-old boy who suffered mild gastrointestinal symptoms after an unintentional ingestion of zinc phosphide. After discussion with the regional Poison Control Center, providers wore powered air-purifying respirators in a negative pressure room and experienced no symptoms of phosphine exposure. The patient was discharged the next day after a complete recovery. Conclusions: Clinicians should be aware of the potential clinical ramifications to patients who ingest zinc phosphide and the potential risks of caring for such patients. To prevent additional exposure, providers should don appropriate personal protective equipment and contact HAZMAT (or local health department) to safely remove additional zinc phosphide.
查看更多>>摘要：? 2022 The AuthorsUnilateral paralysis is an alarming symptom with broad differential diagnoses, including stroke, Todd's paralysis, myelopathy, and peripheral neuropathy. Hypokalemic paralysis (HP), a neuromuscular disorder associated with muscle dysfunction, is caused by hypokalemia and manifests as symmetric proximal extremity muscle weakness. Unilateral paralysis has rarely been reported in the literature. Once hypokalemia is corrected, HP is usually reversible. Delayed diagnosis and treatment may result in fatal consequences. Here, we report an atypical case of unilateral weakness along with a review of the literature on unilateral HP.
查看更多>>摘要：? 2022Contamination of synthetic cannabinoids with toxic coumarin derivatives known as superwarfarins can induce a persistent coagulopathy. In comparison to warfarin, these derivatives have prolonged half-lives and laboratory assays for detection are not readily available in clinical practice. To our knowledge, factor-guided diagnosis of coagulopathy secondary to coumarin-contaminated synthetic cannabinoids has not been described previously. Our case report details a young adult who presented to the hospital with an acute elevation in INR without any reported past medical history or illicit substance use. Factor levels were obtained and resulted quickly revealing deficiencies in factors II, VII, IX, and X, which led to a possible diagnosis of coagulopathy secondary to coumarin-contaminated synthetic cannabinoids. Upon further questioning, the patient admitted to use of synthetic cannabinoids. A bromadiolone assay was sent for testing, which resulted positive after patient discharge. Toxic coumarin derivative assays are not immediately available for reference. Given the patient's confirmed synthetic cannabinoid consumption and the possibility of coagulopathy from coumarin-contamination, factor levels served as a guide for diagnosis and treatment prior to the confirmatory assay. Obtaining factor levels in patients with an unexplained coagulopathy and suspected cannabis or synthetic cannabinoid use may aid clinicians in a more prompt diagnosis and treatment.
查看更多>>摘要：? 2022 Elsevier Inc.A 41-year-old otherwise healthy women presented to the emergency department via emergency services after collapsing after feeling a “slap” on her head while celebrating a national holiday. Physical exam and computed tomography scan showed the presence of a retained ballistic fragment in her high parietal scalp, making her the victim of injury by celebratory gunfire, an illegal, but not uncommon, practice. She was admitted for concussive symptoms, her bullet was removed without incident and after a period of observation she was discharged in stable condition to home.
查看更多>>摘要：? 2022 Elsevier Inc.In recent years, severe or lethal cases of caffeine poisoning after large or massive ingestion of caffeinated tablets have increased in Japan. Here we report the case of a 23-year-old male who ingested high-dose caffeine tablets (total: 32.4 g caffeine) in a suicide attempt. He was transferred to our hospital about 2 h after ingesting the tablets and presented with repeated vomiting and tremor in the trunk and extremities. His respiratory rate was 40 breaths/min, heart rate 240 beats/min, blood pressure 109/77 mmHg, and Glasgow Coma Scale E3V2M5. Blood tests revealed metabolic acidosis compensated with respiratory alkalosis, hyperlactatemia, hypokalemia, hyperglycemia, and leukocytosis. After tracheal intubation, gastric lavage was performed and activated charcoal was administered. The patient gradually became hypotensive (systolic blood pressure < 90 mmHg) with a heart rate > 250 beats/min, and non-sustained ventricular tachycardia frequently occurred. Given the lack of response to intravenous noradrenaline and landiolol, high flow continuous hemodialysis (CHD) was initiated 4 h after tablet ingestion with a blood flow rate of 150 mL/min and dialysate flow rate of 2000 mL/h. This dramatically improved his clinical signs and symptoms, especially during the first 3 h. His serum caffeine concentration was 240.9 μg/mL on admission and 344.0 μg/mL at the initiation of high flow CHD, but rapidly decreased to 153.8 μg/mL 3 h after initiating high flow CHD. Our findings suggest that high flow CHD may be effective in treating cases of severe caffeine poisoning with hemodynamics too unstable for intermittent hemodialysis.
查看更多>>摘要：? 2022 Elsevier Inc.Introduction: Each dialysis session uses approximately 150 to 200 L of water. The winter storm that swept southwest USA saw an unprecedented disruption of water supplies due to which intermittent hemodialysis could not be performed for end-stage renal disease (ESRD) patients. We present 4 cases when continuous renal replacement therapy (CRRT) was utilized to provide urgent hemodialysis in hemodynamically stable, non-critically ill ESRD patients during this time of water supply crisis. Case presentation: Our patients were between the ages 47–62 years old, mostly male. Indications for urgent hemodialysis included volume overload with pulmonary edema and respiratory distress, hypertensive crisis, refractory hyperkalemia, and uremic encephalopathy. The CRRT equipment used included the PRISMAX system for CRRT with M150 filters. Continuous veno-venous hemodialysis (CVVHD) more was used with a dialysate flow rate of 6 L /hour and a blood flow rate of 200/per hour with calculated urea clearance of 100 mL/min. The duration of treatment was 8 h to achieve the target Kt/V of 1.15, comparable to the recommended 1.2 provided by IHD. All patients tolerated the procedure well with the resolution of their acute conditions and normalization of blood pressure and electrolytes. Conclusion: We demonstrate limited CRRT as an alternative to safely manage ESRD patients needing urgent hemodialysis in the scenario of a natural disaster resulting in a water outage.
查看更多>>摘要：? 2022 Elsevier Inc.As physicians attempt to “Choose Wisely” and decrease ionizing radiation, the use of Magnetic Resonance Imaging (MRI) has increased. While MRI does not expose patients to ionizing radiation, it does expose patients to specific risks, such as thermal burns. Unfortunately, obese patients are at the highest risk for MRI-related thermal burns. A 45-year-old female with history of gastric bypass underwent diagnostic MRI of her left shoulder and required sedation due to severe anxiety. On awakening, she noted pain proximal to her right elbow that was treated conservatively. The patient presented to our emergency department a week later with an occult, MRI-related, full-thickness burn. CT scan revealed subcutaneous tissue stranding extending beyond the overlying blister. The burn required debridement twice at the nearest burn center and healed slowly thereafter. Emergency physicians should be aware of the risks of MRI so they can counsel patients prior to diagnostic MRI and adequately evaluate patients with complaints after MRI. Furthermore, patients with MRI-related burns may rarely present with delayed, occult deep-tissue involvement requiring burn center evaluation and treatment.
查看更多>>摘要：? 2022Acute headache is a common emergency department (ED) chief complaint that usually has a benign course. Rare etiologies such as subarachnoid hemorrhage (SAH) can lead to extensive disability or even death. If suspected, SAH requires an intricate and intensive diagnostic investigation. Classic teaching recommends computed tomography head imaging without contrast which, if negative, is followed by lumbar puncture (LP) to rule out SAH. With improvements in computed tomography (CT), practice patterns have begun to adjust to allow computed tomography angiography (CTA) to rule out SAH. This case report describes a 23-year-old woman presenting with headache, neck, and back pain. Her initial CT head and CTA head imaging was negative for SAH. However, 3 days later upon re-presentation to the ED with the same symptoms, an LP was positive for increasing red blood cell count in subsequent tubes. She was transferred to a facility with interventional neurology capabilities where digital subtraction angiography showed a left anterior choroidal saccular aneurysm for which she underwent coiling. Given recent changes in SAH clinical practice guidelines, this case highlights the importance of understanding the current limitations of CT imaging, understanding the risks and benefits of both CT and LP, and always maintaining a high suspicion for especially lethal and disabling conditions such as SAH.
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