The American journal of emergency medicine
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Review Case Reports
Extracorporeal membrane oxygenation for refractory, life-threatening, and herpes simplex virus 1-induced acute respiratory distress syndrome. Our experience and literature review.
We report our first experience of treating an immunocompetent adult patient with acute respiratory distress syndrome (ARDS) due to type 1 herpes simplex (HSV1) pneumonitis, using extracorporeal membrane oxygenation (ECMO). Similar cases reported in literature are reviewed as well. The therapeutic options for this particular complication are discussed. ⋯ Data suggest that severe pulmonary involvement in HVS1 infection associated with septicemia/shock is a rare but often fatal in immunocompetent adult as well. We suggest that ECMO might be the selected treatment for severe refractory ARDS in this clinical scenario. It seems to be an effective and useful ultimate therapeutic strategy for preventing death and furthermore permitting near-full pulmonary function recovery.
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Review Comparative Study
A systematic review of nicardipine vs labetalol for the management of hypertensive crises.
Hypertensive emergencies are acute elevations in blood pressure (BP) that occur in the presence of progressive end-organ damage. Hypertensive urgencies, defined as elevated BP without acute end-organ damage, can often be treated with oral agents, whereas hypertensive emergencies are best treated with intravenous titratable agents. However, a lack of head-to-head studies has made it difficult to establish which intravenous drug is most effective in treating hypertensive crises. ⋯ A MEDLINE search was conducted using the term "labetalol AND nicardipine AND hypertension." Conference abstracts were searched manually. Ultimately, 10 studies were included, encompassing patients with hypertensive crises across an array of indications and practice environments (stroke, the emergency department, critical care, surgery, pediatrics, and pregnancy). The results of this systematic review show comparable efficacy and safety for nicardipine and labetalol, although nicardipine appears to provide more predictable and consistent BP control than labetalol.
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The benefit of emergency reperfusion therapy with fibrinolytics or primary percutaneous coronary intervention in patients with ST-segment elevation (STE) acute myocardial infarction (MI) is well known. However, what is not well known are which subgroups of MI patients with ST-segment depression (STD) on the 12-lead electrocardiogram (ECG) may benefit from emergent reperfusion therapy. Current clinical guidelines recommend against administering emergent reperfusion therapy to MI patients with STD on the ECG unless a true posterior MI is suspected. ⋯ This finding has been reported in MI patients with occlusion of the left main artery, occlusion of the proximal left anterior descending artery, and MI in the presence of severe multivessel coronary artery disease. Because these patients have a higher mortality in the setting of MI, we believe that this ECG finding be considered a STEMI equivalent and that patients with this finding receive consideration for emergent reperfusion therapy preferably at a center with both primary percutaneous coronary intervention and coronary artery bypass grafting capability. In this report, we present 3 such patients to heighten the awareness of the emergency physician to this phenomenon.
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Comparative Study Clinical Trial
Noninvasive detection of elevated intracranial pressure using a portable ultrasound system.
The aim of this study is to prospectively compare the accuracies of transcranial color-coded sonography (TCCS) and transcranial Doppler (TCD) in the diagnosis of elevated intracranial pressure. ⋯ This work is a pilot study comparing TCCS and TCD in the detection of elevated ICP. This study suggests that a bedside portable ultrasound system may be useful to determine MCA PI with accuracy similar to that of a dedicated TCD device.
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Multicenter Study
Antimicrobial resistance in uncomplicated urinary tract infections in 3 California EDs.
Increased trimethoprim/sulfamethoxazole (TMP/SMX) resistance has led to changes in empiric treatment of female urinary tract infections (UTI) in the emergency department (ED), particularly increased use of fluoroquinolones (Acad Emerg Med.2009;16(6):500-507). Whether prescribing changes have affected susceptibility in uropathogens is unclear. Using narrow-spectrum agents and therapy tailored to local susceptibilities remain important goals. ⋯ In our population of ambulatory female ED patients, resistance to TMP/SMX is just below the 20% threshold that the Infectious Disease Society of America recommends for continued empiric use (Clin Infect Dis.1999;29(4):745-758, Clin Infect Dis.2011;52(5):e103-120), whereas resistance to other narrow-spectrum agents, such as nitrofurantoin and cephalexin, may be lower than published antibiograms for our sites. Fluoroquinolone resistance remains very low.