J Emerg Med
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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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Review Case Reports
Stress Cardiomyopathy Caused by Diving: Case Report and Review of the Literature.
Stress cardiomyopathy is characterized by transient myocardial dysfunction that mimics a myocardial infarction in the absence of obstructive coronary artery disease. The onset is frequently triggered by an acute illness or intense physical or emotional stress. ⋯ We describe the case of a 47-year-old woman who was brought to the emergency department with acute onset shortness of breath while scuba diving. She was found to have acute pulmonary edema radiographically. Her troponins were noted to be positive. Initial echocardiogram showed basal hypokinesis with hyperkinesis of apex. She was treated with noninvasive ventilation and intravenous diuretic therapy and her symptoms significantly improved. She subsequently underwent cardiac catheterization which revealed nonobstructive coronary artery disease. An exercise stress echocardiogram was performed 2 days later that revealed resolution of the wall motion abnormality and no ischemia at high levels of exercise. A diagnosis of reverse stress (Takotsubo) cardiomyopathy was made based on Mayo Clinic Diagnostic criteria. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case brings to light the risk of stress cardiomyopathy in divers. The diagnosis should be considered in patients presenting with acute pulmonary edema during diving.
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Respiratory distress and tachycardia are common presenting complaints in infants and young children, and evaluation typically focuses on respiratory infections. Tachydysrhythmias causing heart failure are rare and can be difficult to diagnose in young children, but are reversible if recognized and treated early. ⋯ We discuss a 7-week-old female infant who presented with respiratory distress and persistent tachycardia. Evaluation revealed severe cardiac dysfunction with an underlying atrial flutter discovered on electrocardiography after adenosine administration. Rate control by synchronized electrocardioversion resulted in resolution of symptoms and restoration of cardiac function, confirming the diagnosis of atrial flutter-induced cardiomyopathy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Persistent or inappropriate tachycardia in a young child should not be dismissed and underlying dysrhythmia should be considered.
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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.
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Observational Study
High Body Mass Index is Strongly Correlated with Decreased Image Quality in Focused Bedside Echocardiography.
There is a well-established relationship between obesity, as measured by body mass index (BMI), and overall health risk. The presence of body fat is a known limitation to ultrasound, but it is unknown whether any decrease in quality due to obesity limits the interpretability of focused bedside echocardiography (FBE). ⋯ There is an overall decrease in the quality of focused bedside echocardiographic images as BMI increases. This relationship exists for visualization of both the PMI and the ELV. Emergency physicians should be aware of the potential limitations of focused bedside echocardiography in this patient population.