J Emerg Med
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Resuscitation without return to spontaneous circulation in patients with suicidal ingestion of cardiotoxic drugs necessitates alternative bridging therapies for drug removal. ⋯ ECMO and plasma exchange should be considered as a therapeutic option in selected patients under resuscitation without return to spontaneous circulation after severe intoxication.
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Recent clinical advances with new mechanical circulatory systems have led to additional strategies in the treatment of end-stage heart failure. The third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a blood pump and a driveline (cable) that exits the patient's skin connecting the implanted pump to an externally worn controller. We report a rare case of a HeartWare LVAD driveline rewiring after accidental (presumed) transection of the driveline system. ⋯ A 67-year-old male with a medical history of ischemic cardiomyopathy status post HeartWare LVAD implantation presented to the emergency department (ED) after acute LVAD failure. On the morning of presentation, he attempted to cut the paper tape off of his adult diaper with scissors and accidentally (presumed) and unwitnessed severed the driveline system. The patient immediately went into cardiac arrest and was transported to a regional medical center. On arrival, he exhibited no appreciable vital signs and was subsequently intubated, vascular access was placed, and inotropic support initiated. The emergency physician individually stripped and reconnected the color-coded driveline wires using multiple hemostats, electrical tape, and cardboard, which resulted in regeneration of positive LVAD flows. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VAD patients will present in extremis typically to the ED with manifestations of pump dysfunction ranging from diminished flows needing fluid management or pump adjustments to full pump failure manifesting as cardiogenic shock, needing rapid resuscitation and transfer to a cardiothoracic surgical unit with on-site VAD-perfusion specialists.
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Skin and soft-tissue infections (SSTIs) are common disease presentations to the emergency department (ED), with the majority of the infections attributed to community-acquired methicillin-resistant Staphylococcus aureus. Rapid and accurate identification of potentially serious SSTIs is critical. Clinician-performed ultrasonography (CPUS) is increasingly common in the ED, and assists in rapid and accurate identification of a variety of disease processes. ⋯ A 21-year-old female presented to the ED with chin swelling and "boils." Although her visual examination was benign, CPUS of her facial swelling quickly established a more concerning disease process, which was eventually confirmed by aspiration and bone biopsy to be mandibular osteomyelitis. The causative organism, Serratia odorifera, is rarely associated with infections, and we are aware of no previously reported cases of osteomyelitis due to this species. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case of mandibular osteomyelitis, CPUS rapidly and accurately identified abnormal bony cortex of the mandible and an associated fluid collection. CPUS of an otherwise benign presentation of a facial infection led to a maxillofacial computed tomography scan, aspiration and biopsy, and then elective debridement of the bone infection. Emergency physicians should be aware of the utility of CPUS and the need to carefully investigate SSTIs presenting to the ED.