The American journal of emergency medicine
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Case Reports
A case of intracranial hemorrhage after a single dose of Yohimbine in a chronic user of clonidine.
Yohimbine, an alpha-2 adrenoreceptor antagonist found in a variety of supplements, has been historically used to treat libido, erectile dysfunction, xerostomia, and as a weight loss enhancement. Yohimbine toxicity causes a sympathomimetic syndrome as demonstrated by the case below of a female who developed an intracranial hemorrhage (ICH) following an ingestion of yohimbine. ⋯ Dietary supplements are not required by the FDA to undergo efficacy or safety testing, necessitating clear post-marketing communication regarding potential adverse events from various supplements. Users should be aware of yohimbine-containing products and the possible side effects of toxicity. It is crucial that physicians and patients be aware of possible drug-supplement interactions of yohimbine and the presentation of sympathomimetic syndromes.
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Case Reports
Recreational drug toxicity with severe hyperthermia: Rapid onsite treatment and clinical course.
Electronic dance music festivals have gained notoriety in the critical care and emergency medicine fields due to an alarming incidence of hospitalizations and deaths related to the high prevalence of recreational drug use. Recreational drug use toxicity, in part related to sympathomimetic toxidromes, may cause hyponatremia, seizures, rhabdomyolysis, hyperkalemia, acidosis, coagulopathy, circulatory shock, multi-organ failure, and even death. ⋯ Rapid onsite diagnosis and treatment, with attention to the A-B-C's of clinical emergencies, is essential to preserve life. We describe a patient presenting with the highest recorded core temperature in a survivor of psychostimulant drug-induced toxicity, and emphasize management principles of this life-threatening and increasingly prevalent condition.
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Obstructive shock is often associated with poor right ventricular (RV) output and requires rapid obstruction release. A 54-year-old man was brought to our emergency department, presenting with shock. He had previously undergone esophagectomy with gastric interposition through the retrosternal route, after which he could not eat solid foods. ⋯ Anatomically, the retrosternal route is located directly in front of the RV. Thus, it is thought that the massively dilated gastric tube externally compressed the RV, preventing adequate RV filling and causing the obstructive shock. In such cases, the patient's position should be changed immediately to release the RV compression.
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Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. ⋯ As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.
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Observational Study
The LIMIT-NI clinical decision instrument reduces neuroimaging compared to unstructured clinician judgement in recurrent seizure patients.
The LIMIT clinical decision instrument (CDI) was published in 2021 to safely reduce neuroimaging in patients with recurrent seizures. The LIMIT CDI had a sensitivity of 90%, negative predictive value of >99.9%, and reduced neuroimaging by 13.3%. However, the design of the original LIMIT CDI made it cumbersome to use. The goal of this study was to validate the streamlined LIMIT-NeuroImaging (LIMIT-NI) CDI and compare its performance to the original LIMIT CDI. ⋯ The LIMIT-NI CDI demonstrated greater ease of application and improved test characteristics compared to the original LIMIT CDI. Compared to unstructured clinician judgement, the LIMIT-NI CDI reduced neuroimaging by 15.8% (relative reduction 40.2%) in recurrent seizure patients. The LIMIT-NI CDI can be used by physicians along with clinical judgement to reduce neuroimaging in the recurrent seizure patient.