J Emerg Med
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Comparative Study
Impact of Clinical Pharmacists on Initiation of Postintubation Analgesia in the Emergency Department.
Pain and anxiety are common in mechanically ventilated patients, and frequently undertreated in the emergency department (ED) setting. ⋯ Analgesic use after RSI in the ED significantly increased after the implementation of ED pharmacy services. The large proportion of patients receiving analgesia during the EDP duty hours suggest the increase may be related to direct pharmacist involvement in postintubation management.
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Case Reports
Pediatric Urinary Retention in the Emergency Department: A Concerning Symptom with Etiology Outside the Bladder.
Urinary retention in an otherwise healthy adolescent is a concerning symptom, in which etiology can range from an extracystic mass to central nervous system involvement (CNS). One possibility is acute disseminated encephalomyelitis (ADEM), a rare inflammatory autoimmune disease that affects the CNS via demyelination. The disease usually is preceded by an acute viral infection, and commonly presents with multifocal neurological deficits. The diagnosis for ADEM is made based on clinical presentation, correlating with findings characterized on magnetic resonance imaging (MRI) in the CNS. ⋯ Our case involves a 16-year-old boy who presented to the Emergency Department (ED) with urinary retention. The patient was an otherwise healthy adolescent who was experiencing intermittent fevers for 1 week, and was found to be monospot positive when seen by his pediatrician. When presenting to the ED, the patient's primary complaint was urinary retention, which he experienced acutely in the middle of the night. Due to the suspicious nature of the patient's symptoms and history of present illness, the patient received a thorough workup including magnetic resonance imaging (MRI) of the patient's brain and spinal cord, which demonstrated findings consistent with ADEM. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: There is very little literature describing a case of ADEM in the ED where the primary manifesting symptom was urinary retention. In addition, it is important that clinicians address acute urinary retention in an otherwise healthy adolescent as a red flag, with the need to rule out concerning etiology.
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Review Case Reports
Emergency Department Management of a Myasthenia Gravis Patient with Community-Acquired Pneumonia: Does Initial Antibiotic Choice Lead to Cure or Crisis?
Myasthenic crisis is a rare, yet serious condition that carries a 3%-8% mortality rate. Although infection is a common cause of decompensation in myasthenia gravis, several antibiotics classes have also been associated with an exacerbation. Selecting antibiotics can be a daunting clinical task and, if chosen inappropriately, can carry significant deleterious consequences. Not only do clinicians have to focus on treating the underlying infection appropriately, but avoiding antibiotics that may potentiate a myasthenic crisis is also vital. ⋯ An 85-year-old female with a history of myasthenia gravis presented to the emergency department (ED) with increasing generalized weakness and shortness of breath. Clinical work-up was consistent with a community-acquired pneumonia (CAP) diagnosis. Her medical history included a myasthenia gravis exacerbation shortly after receiving moxifloxacin for CAP. After reviewing the patient's allergies, as well as potential antibiotic triggers, the decision was made to treat with tigecycline. The patient responded well to tigecycline therapy and was deemed stable for discharge on day 4 of hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Evaluation of the myasthenia gravis patient frequently originates in the ED. It is important for clinicians to be able to distinguish between an underlying illness and a myasthenic crisis. In the event of an infectious process causing clinical deterioration in a myasthenia patient, optimal antibiotic selection becomes paramount. This patient case highlights the addition of tigecycline to the armamentarium of therapies available to treat myasthenia gravis patients presenting to the emergency department with CAP.
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Hospitals are rarely reported as settings for mass psychogenic illness (MPI). The present report scrutinizes an outbreak of probable MPI among hospital staff, with medical intervention reinforcing the course of the illness. ⋯ Four of seven staff members in an emergency department became acutely ill with nonspecific symptoms. After uneventful observation they were discharged, but symptoms worsened at reassembly for debriefing. Poisoning with hydrogen sulfide was suspected, and the victims were transferred by helicopter for hyperbaric oxygen (HBO) treatment. During the following 9 days, 14 possible poisoning victims were identified, 6 of whom were transferred for HBO. After hospital stays with repeated HBO treatment and examinations without identification of significant physical disease, the majority of the 10 HBO-treated victims remained symptomatic, some on prolonged sick leave. The ward was closed for several weeks during comprehensive but negative investigations for toxic chemicals. Clinical data and lack of indication of chemical exposure, together with an attack pattern with only some individuals becoming ill in a shared environment, suggest MPI. Iatrogenic influence from dramatic intervention was probably a strong driving force in the outbreak. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Awareness of MPI may prevent unnecessary and potentially harmful treatment as well as improve health care resilience, particularly with respect to preparedness. Outbreaks of illness in a group of symptomatic victims without indication of significant physical disease should be managed by observation and limited intervention.
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Comparative Study
Emergency Department Expansion Versus Patient Flow Improvement: Impact on Patient Experience of Care.
Most strategies used to help improve the patient experience of care and ease emergency department (ED) crowding and diversion require additional space and personnel resources, major process improvement interventions, or a combination of both. ⋯ Our results demonstrate that the impact of process improvement and rapid assessment implementation is far greater than the impact of renovation and facility expansion.