The American journal of emergency medicine
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We conducted an explanatory, sequential mixed-methods study to measure variation in the use of imaging and physical therapy (PT) for acute low back pain (LBP) and to identify implementation determinants that might explain variation in use across 22 EDs and 27 urgent cares in urban and rural locations within a community-based health system. ⋯ Guideline concordance for use of imaging and PT varied substantially across physicians and advance practice providers providing care at EDs and UC centers within a community-based health system. Implementation strategies that address barriers identified by this study, including varied understanding of the PT discipline, complex workflows for placing PT referrals, the medico-legal assurance that imaging provides, and the lack of feedback loops in ED and UC centers should be tested in future hybrid implementation-effectiveness trials to increase concordance to LBP guidelines and minimize harm related to overuse of imaging and underuse of conservative first-line treatment approaches.
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Chronic pruritus accounts for approximately 1 % of all physician visits, and providers are often confronted with how to treat patients with pruritus. Scabies is oftentimes a concern by both patients and providers, and anti-scabietic treatments are generally considered safe and effective. However, the pruritus will continue if there is an alternate etiology. ⋯ While scabies is one cause of chronic pruritus, its misdiagnosis may increase the chance that at-risk individuals, often those with prior substance abuse or psychiatric disorders, develop a persistent concern for ongoing infestation. It is possible that, in treating chronic pruritus with repeated empiric anti-scabietic treatments, the prescribing physician may contribute to the development of DI. We review the approach to a patient with chronic pruritus and ways to avoid unnecessary repeated anti-scabietic treatments.
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Previous self-harm attempts are a known risk factor for subsequent suicide completion in adults but is unestablished among adolescents and young adults. Our objective was to determine the mortality rate for patients 10-24 years of age following discharge from the hospital after a non-lethal, intentional overdose. ⋯ Our observed mortality was lower compared to other studies (0.7 % - 13.3 %), which may have been due to protective factors (e.g., multidisciplinary evaluations) built into the institutional protocols at this center. Future studies will attempt to qualitatively and quantitatively identify individual- and system- level mechanisms in the pathway between self-harm and long-term health outcomes.
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Gastroduodenal intussusception is a rare but important cause of gastric outlet obstruction, particularly in elderly patients. We present the case of an 81-year-old female who arrived at the emergency department with complaints of epigastric pain, nausea, and vomiting. A CT scan revealed gastroduodenal intussusception, while subsequent endoscopy identified a submucosal mass, raising suspicion for either a gastrointestinal stromal tumor (GIST) or pancreatic rest. This case report highlights the diagnostic process, therapeutic considerations, and clinical outcomes, with a review of the relevant literature.
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Case Reports
Delayed diagnosis of pediatric bladder rupture with atypical presentation after a minor fall.
Pediatric bladder injuries, though uncommon, typically result from blunt trauma, often associated with motor vehicle collisions. While most bladder injuries are linked to pelvic fractures, this association may be less common in children due to anatomical differences. Bladder injuries are classified as extraperitoneal, intraperitoneal, or combined, with intraperitoneal injuries being rarer but more prevalent in children due to their higher abdominal bladder position. This case report discusses a rare instance of delayed intraperitoneal bladder rupture in a young child following a relatively minor fall, emphasizing diagnostic challenges. ⋯ A 4-year-old female presented with new onset abdominal pain, vomiting, and subjective fever three days after a minor fall. Initial evaluation revealed diffuse abdominal tenderness, elevated creatinine, and moderate ascites on ultrasound with no gross hematuria. Despite treatment for presumed acute kidney injury, the patient's condition worsened, leading to the identification of a large posterior dome bladder rupture via cystography. Surgical repair was performed, and the patient was discharged with a full recovery after sequential removal of urinary catheters. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intraperitoneal bladder rupture can occur in healthy children after minor trauma and may not present acutely with the classic signs of gross hematuria and peritonitis. Emergency physicians should consider this diagnosis in young children with unexplained ascites, abdominal pain, hematuria, and renal failure, even with only a remote history of minor abdominal trauma.