The American journal of emergency medicine
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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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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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In this study, we aimed to explore the association between the choice of empirical antibiotic therapy and outcomes in ED patients with sepsis. ⋯ Empirical combination antibiotic therapy was not associated with reduced mortality in ED patients with sepsis. Compared with cephalosporins, penicillins and vancomycin, quinolone mono-antibiotic therapy was significantly associated with a decreased risk of in-hospital mortality, especially in patients with respiratory tract infections.
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Diagnosis of cryptococcal meningitis is typically aided through CSF analysis obtained via lumbar puncture (LP), revealing elevated WBCs, increased protein, decreased glucose, and increased opening pressure. While CSF culture confirms the diagnosis, it takes days, prompting reliance on these adjuncts. AIDS from Human Immunodeficiency Virus is less commonly diagnosed in the emergency setting due to advances in testing and treatment. ⋯ This case underscores that C. neoformans can present with normal CSF studies, delaying diagnosis and treatment, highlighted by the fact that this patient went undiagnosed in the preceding 3.5 weeks. CSF cryptococcal antigen and opening pressure are critical diagnostic tools, enabling timely antifungal therapy. Given the high mortality rate, early empirical treatment is essential, especially in high-risk patients, even when CSF findings seem normal.