The American journal of emergency medicine
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Use of opioids for treatment of headache in the emergency department (ED) is associated with an increased 1-year risk of opioid-related adverse events. ⋯ Opioid prescriptions are associated with ED revisits, hospitalizations and LTU in headache patients, without improved efficacy. These findings support the growing notion that opioids are not indicated for ED headache management.
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Case Reports
Iatrogenic STEMI in a male trauma patient due to coronary artery compression by a left sided chest tube.
Iatrogenic ST segment elevation myocardial infarction (STEMI) after insertion of a left sided thoracic tube is a rare insertional complication. We present a case of coronary artery compression of the left anterior descending artery (LAD) caused by a left sided chest tube placed after blunt thoracic trauma with pneumothorax resulting in a STEMI. A 53-year-old male patient with severe blunt thoracic trauma presented in the emergency department. ⋯ Complications after chest tube insertion can occur in up to 30 % of patients. However, no similar case with iatrogenic ST segment elevation myocardial infarction due to compression of a coronary artery has been reported in the literature so far. Knowledge of the possible complications of an intervention is important and a 'high level of suspicion' is required in order to recognize and resolve them quickly.
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Case Reports
Should digoxin immune fab be administered based solely on reported ingested amount in acute digoxin poisoning?
Acute digoxin poisoning is increasingly uncommon in emergency medicine. Furthermore, controversy exists regarding indications for antidotal digoxin immune fab in acute poisoning. In healthy adults, the fab prescribing information recommends administration based on "known consumption of fatal doses of digoxin: ≥10mg," while many emergency medicine textbooks suggest fab administration be driven by clinical features or potassium concentration. ⋯ Serum digoxin concentration drawn on hospital arrival resulted after death at 44 ng/mL. In this fatal case of acute digoxin poisoning, fab was not empirically recommended because the patient initially did not have significant signs or symptoms that accompanied the history of ingesting ≥10 mg digoxin. While the bedside team was given clear anticipatory guidance by the regional poison center, the patient died despite fab administration once instability occurred.
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Patient-reported penicillin allergies are frequently encountered in the emergency department (ED), which often lead to non-beta-lactam antibiotic use despite beta-lactams' place as first-line therapy in most bacterial infections. The PEN-FAST clinical decision tool was developed and validated to identify patients with a low risk of true penicillin allergies that do not require formal skin testing for rechallenging. The tool consists of four questions that add up to a total score ranging from 0 to 5. Scores of 0-2 are associated with low risk of true penicillin allergy (<5% risk of true reaction); scores of 3 with moderate risk (<20% risk); and scores of 4-5 with high risk (50% risk). The purpose of our study was to determine the safety and efficacy of our facility's implementation of pharmacist utilization of the PEN-FAST screening tool to assess purported penicillin allergies and rechallenge low to moderate risk patients in the ED. ⋯ In this prospective, observational study, administration of beta-lactam antibiotics to ED patients with previously reported penicillin allergies and a PEN-FAST score less than 3 did not result in any immune-mediated reactions. The PEN-FAST decision tool was able to safely identify and risk-stratify eligible patients for beta-lactam rechallenge in the ED.