The American journal of emergency medicine
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Case Reports
Acute myocardial infarction in the setting of left bundle branch block: Chapman's sign.
Acute myocardial infarction (AMI) diagnosis in patients with pre-existing left bundle branch block (LBBB) can be difficult. Undiagnosed or delayed diagnosis of AMI in these patients can put them at risk of having shock, mechanical complications, and death. We present a case of 77-year-old Caucasian male with a known LBBB and coronary artery bypass surgery for coronary artery disease who presented to the emergency department with a chief complaint of chest pain and shortness of breath. ⋯ Troponin levels were initially normal, but serial troponin showed elevated enzyme giving evidence of acute coronary syndrome (ACS). The patient was started on heparin drip and underwent subsequent coronary catheterization. Physicians should be aware of Chapman's sign on ECG in patients presenting with chest pain who have baseline LBBB as it might represent myocardial ischemia and warrant emergent treatment for ACS.
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Mechanical ventilation can cause deleterious effects on the lung and thus alter patient's prognosis. The aim of this study was to describe the characteristics of prehospital mechanical ventilation in patients with septic shock requiring mechanical ventilation in the prehospital setting. ⋯ In this retrospective study, we observed an association between mortality at day 28 and prehospital VTIBW in pre-hospital mechanically ventilated patients with septic shock. A VTIBW <8 ml·kg-1 was associated with a decrease and a VTIBW >8 ml·kg-1 with an increase in mortality.
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Emergency Department Observation Units (Obs Units) provide a setting and a mechanism for further care of Emergency Department (ED) patients. Our hospital has a protocol-driven, type 1, complex 20 bed Obs Unit with 36 different protocols. We wanted to understand how the different protocols performed and what types of care were provided. ⋯ An Obs Unit can care for a wide variety of patients who require multiple consultations, procedures, and care coordination while maintaining an acceptable length of stay and admission rate.
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Case Reports
Citalopram overdose and severe serotonin syndrome in an intermediate metabolizing patient.
Citalopram is a selective serotonin reuptake inhibitor used for treatment of depression. Metabolism is primarily through CYP3A4 and CYP2C19; activity of the latter can vary depending on genetics. Although rare after single agent exposure, large citalopram ingestions can lead to serotonin syndrome. We report a case of citalopram overdose in an intermediate CYP2C19 metabolizer complicated by severe serotonin syndrome. ⋯ Citalopram overdose may be associated with severe serotonin syndrome and further investigation is warranted to understand the impact of enzyme genotype on toxicity.
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Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. PI can be both asymptomatic and life-threatening. The patient was a 50-year-old man with previous cervical spine abscess and osteomyelitis post debridement 4 years ago, with a heroin abuse history. ⋯ Finally, he was discharged 5 days later with a nasojejunal and drainage tubes and was arranged for OPD follow-up. PI can be asymptomatic or life-threatening, and patient management varies based on the clinical condition. Although in this case PI was found in the emergency department, a patient's past history of underlying disease and medication should be reviewed to find the most possible etiology.