J Emerg Med
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Observational Study
Emergency Department Crowding in Relation to In-hospital Adverse Medical Events: A Large Prospective Observational Cohort Study.
Emergency department (ED) crowding has been linked with adverse medical events. However, this association was inadequately controlled for potential confounding variables. ⋯ Failing to control for baseline risk factors may have led to false-positive associations between ED crowding and mortality in previous studies. After controlling for risk factors, we showed that ED crowding was associated with longer hospital stays but not with increased mortality.
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Active shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders. ⋯ Developing and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival.
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Angiotensin-converting enzyme (ACE) inhibitor-induced angioedema is a rare, albeit serious emergency that can result in airway compromise and potentially death if not treated promptly. Currently, there are no agents approved by the Food and Drug Administration to target ACE inhibitor angioedema and to prevent intubation. C1 inhibitors are approved for hereditary angioedema but may show promise in alleviating inflammation associated with ACE inhibitor angioedema. ⋯ A 41-year-old man presented to the emergency department with swelling of his lips a few days after starting lisinopril for hypertension. Despite receiving diphenhydramine, ranitidine, and methylprednisolone, the swelling progressed to the patient's tongue. A C1 inhibitor was ordered in an effort to prevent intubation. Before the arrival of the medication, the patient was intubated emergently for airway protection. After receipt of the C1 inhibitor, the swelling dramatically improved, and the patient was successfully extubated after less than 18 hours from presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates a potential role for C1 inhibitors in the emergency setting for treating drug-induced angioedema, which may prevent or minimize mechanical ventilation time.
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Case Reports
Late Postpartum Eclampsia with Postpartum Angiopathy: An Uncommon Diagnosis in the Emergency Department.
Late postpartum eclampsia is defined as occurrence of eclampsia >48 h after delivery and is a rare clinical entity. The delayed onset and nonspecific symptoms at presentation make this entity a challenge to diagnose in patients presenting to the emergency department (ED); however, early recognition and timely interventions are the keys to reducing morbidity and mortality in patients with late postpartum eclampsia. ⋯ A 28-year-old woman presented to our ED with a chief complaint of headache of 4 days duration, 8 days after an uncomplicated, normal vaginal delivery. Her past medical history was unremarkable and her entire pregnancy was without medical incident. The patient's examination was within normal limits other than a blood pressure of 152/111 mm Hg and pulse of 54 beats/min. Given her undifferentiated headache and the possibility of preeclampsia, the patient was treated with magnesium sulfate, which was subsequently stopped due to worsening bradycardia. Hydralazine was administered for blood pressure control. Three hours after the magnesium was stopped, the patient reported blurry vision, which was immediately followed by a generalized tonic-clonic seizure. After the seizure, lorazepam was given for control of seizures, and the patient was admitted to the medical intensive care unit. The patient was transferred to the postpartum floor 6 days later in stable condition and without any further seizure activity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with late postpartum eclampsia are infrequently encountered in the ED due to the rarity of this condition. Increased awareness of this entity among emergency physicians will lead to early interventions, which are crucial in decreasing morbidity and mortality in these patients.
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Hip fractures are common injuries, particularly among elderly patients. Although plain radiographs are the initial imaging modality of choice, approximately 10% of hip fractures are not radiographically evident. Failure to diagnose a hip fracture in the emergency department may result in delayed diagnosis and potentially devastating consequences. ⋯ We report the case of an 81-year-old woman with right hip pain after a fall. Although plain radiographs of the right hip and femur were negative for fracture, point-of-care ultrasound of the right hip demonstrated a cortical disruption in the femur consistent with a fracture. Given the clinical and ultrasound findings, computed tomography of the bony pelvis and proximal femurs was performed, which confirmed an oblique complex fracture of the right femur through the greater and lesser trochanters. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound, in conjunction with clinical suspicion, may help identify patients who require more advanced imaging to identify occult hip fractures.