J Emerg Med
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Alcoholic ketoacidosis (AKA) is a complex syndrome that results from disrupted metabolism in the setting of excessive alcohol use and poor oral intake. Dehydration, glycogen depletion, high redox state, and release of stress hormones are the primary factors producing the characteristic anion gap metabolic acidosis with an elevated β-hydroxybutyrate (β-OH) and lactate. ⋯ We present the case of a 47-year-old man who presented to the emergency department with metabolic acidosis and profoundly elevated lactate levels who had AKA. He recovered completely with intravenous fluids and parenteral glucose administration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should always consider the immediately life-threatening causes of a severe anion gap metabolic acidosis and treat aggressively based on the situation. This case highlights the fact that AKA can present with an impressively elevated lactate levels. Emergency physicians should keep AKA in the differential diagnosis of patients who present with a similar clinical picture.
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It has been speculated that freestanding emergency departments (FEDs) draw more affluent, better-insured patients away from urban hospital EDs. It is believed that this leaves urban hospital-based EDs less financially secure. ⋯ There were less privately insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. Privately insured patients decreased at both the FEDs and main ED during the study. Insurance distribution was significantly different between the main ED, and three FEDs, and between individual FEDs.
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Fractures are a frequent reason for emergency department visits and evaluation for abusive head trauma is an associated concern in infants. Recent guidelines have suggested that retinal examination may not be necessary in the absence of intracranial injury, but there is a lack of empirical evidence in infants < 1 year of age. ⋯ In infants < 1 year of age presenting with isolated long bone fractures, a dilated eye examination to evaluate for retinal hemorrhages is not likely to yield additional information. Our results support recent studies that a subset of children and infants may not require dilated eye examinations in the evaluation of possible abuse.
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Lingual abscess is a rare clinical entity, with posterior involvement being much less common than anterior involvement. Typical inciting events include trauma or direct inoculation to the area. The clinical diagnosis can be difficult, and early imaging and specialist consultation should be pursued to make a definitive diagnosis and to prevent patient deterioration. ⋯ We present a case of posterior lingual abscess in a 62-year-old man after he received antibiotic injections to the lower molars for periodontal disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Lingual abscess is a rare condition that is difficult to diagnose clinically. Misdiagnosis or delayed diagnosis can lead to acute airway compromise and increased morbidity.
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Renal colic caused by stone(s) is common in the emergency department. Often, urinalysis reveals white blood cells, but it is unknown how frequently pyuria is sterile or infectious. ⋯ Pyuria was found in 14.2% of patients with renal colic. Patients with pyuria had 36.4% positive cultures compared to 3.3% of patients without pyuria. The degree of pyuria or leukocyte esterase was significantly associated with the risk of a positive culture. Urine cultures are recommended for all patients with renal colic and pyuria.