The American journal of emergency medicine
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We present a case of a 39-year-old woman presenting to the emergency department with persistent vaginal bleeding with myoma and endometrium thickness. The qualitative urine human chorionic gonadotropin (hCG) showed positive result, however, the quantitative serum hCG had negative result. The negative serum hCG result suggests that the false-positive result was not caused by elevated circulating hCG. ⋯ On the basis of our findings, the false positive pregnancy test was not caused by hemoglobin. It is important to confirm a suspected false-positive urine hCG test using a quantitative serum hCG test. Although it is not certain the mechanism for false positive reaction in this peculiar sample, the ACON urine hCG one-step pregnancy will occasionally yield a false-positive result in this class of patients.
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Myxedema coma is the most lethal manifestation of hypothyroidism. It is a true medical emergency and can result in profound hemodynamic instability and airway compromise. Myxedema coma currently remains a diagnostic challenge due to the rarity of cases seen today, and failure to promptly initiate therapy with replacement thyroid hormone can be fatal. ⋯ We describe a case of an unidentified woman who presented to the ED with myxedema coma requiring urgent endotracheal intubation and was found to have extensive posterior pharyngeal angioedema inconsistent with her relatively benign external examination. This case highlights the typical features of myxedema coma and discusses our necessity for a rescue device in definitive endotracheal tube placement. Emergency physicians should anticipate a potentially difficult airway in all myxedema coma patients regardless of the degree of external facial edema present.
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Editorial Comment
Ethics, equipoise, and evidence: when should investigators decide to not test their hypothesis.
In an excellent investigation of endotracheal tube cuff pressure assessment, "Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport," Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits. ⋯ Our hope is that readers will acknowledge the study of Chapman et al as a strong piece of evidence indicating that patients who undergo endotracheal intubation without measurement of endotracheal tube cuff pressure very likely have a pressure that exceeds the safe range. We hope this study, in conjunction with the other available evidence, will prompt readers to adopt measurement of endotracheal tube cuff pressure as a routine.
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Prolonged endotracheal tube cuff pressures (ETTCPs) greater than 30 cm H(2)O cause complications ranging from sore throat to rare cases of tracheoesophageal fistula. In a series of patients, we sought to determine the proportion of patients with overinflated cuffs and to determine whether overinflation was associated with demographics, diagnostic category, or intubator credentials. ⋯ The most compelling results of the study are the high rates of elevated ETTCPs. Furthermore, there were no clear risk factors for elevated ETTCP. Although the risk of elevated ETTCP in the prehospital to acute care time frame is unclear, it seems reasonable to measure ETTCP after intubation in all patients.
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Case Reports
Acute appendicitis presenting with Klebsiella pneumoniae septicemia due to bacterial translocation.
Bacterial translocation (BT) is defined as the passage of viable bacteria from the gastrointestinal tract, across the intestinal wall, to the mesenteric lymph nodes or other extranodal sites and bloodstream. It has been shown in both animal and human studies and has been implicated as a source of sepsis in susceptible patients. ⋯ Thorough clinical investigation ruled out other sources of infection. Emergency physicians should be aware that septicemia may be the dominant presentation of acute appendicitis, due to dissemination of the infection into the bloodstream, secondary to bacterial translocation.