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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Reversal of oral factor Xa (FXa) inhibitors, such as apixaban, remains a controversial topic. However, the controversy goes beyond what reversal agent to utilize. ⋯ A paucity of literature exists regarding the utilization of low molecular weight heparin (LMWH) anti-Xa assays and thromboelastography for identifying coagulopathies associated with oral FXa inhibitors. We report a case of apixaban induced coagulopathy utilizing thromboelastography and a LMWH anti-Xa assay as a guide for reversal.
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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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To evaluate the significance of sonographic perinephric fluid collection on the emergent management of patients with acute urinary stone obstruction. ⋯ This study shows a correlation between sonographic evidence of perinephric fluid and more severe pain. Therefore, an emergency physician can consider the evidence of perinephric fluid, in acute urethral stone obstruction, a predictor for more severe pain.