J Emerg Med
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Emergency departments (EDs) in the United States play a prominent role in hospital admissions, especially for the growing population of older adults. Home-based care, rather than hospital admission from the ED, provides an important alternative, especially for older adults who have a greater risk of adverse events, such as hospital-acquired infections, falls, and delirium. ⋯ Results suggest that EPs recognize there is a benefit to providing home-based care as an alternative to hospitalization, provided they felt the home was safe and a process was in place for dispositioning the patient to this setting. Better understanding of when and why EPs use home-based care pathways from the ED may provide suggestions for ways to promote wider adoption.
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Ambulance crashes delay patient transfer and endanger patients, ambulance crews, and other road users. In low- and middle-income countries, where motor vehicle crash rates are typically high, ambulances have a high risk of being involved in a crash. This case report describes an ambulance crash in Thailand to elucidate modifiable problems in current protocols and practices of emergency medical services. ⋯ In November 2016, a 28-year-old male driver of an ambulance died in a crash while transferring a female patient with dizziness to a rural hospital. The driver and another ambulance crew member were sitting in the front seats unrestrained. The other occupants were in the patient compartment unrestrained. The driver was driving the ambulance within the speed limit. He made a sharp turn trying to evade a dog, and the ambulance crashed head-on into a roadside tree. The cabin sustained severe damage, and the occupants in the patient compartment were struck against the compartment wall and were struck by unsecured equipment and the stretcher. The driver sustained a severe brain injury. The other occupants, including the female patient, sustained minor injuries. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case raises safety issues concerning the following aspects of ambulance operations in low- and middle-income countries: speed limit, safety device use, seatbelt use, securing equipment, and vehicle safety standards. Systematic measures to change protocols or even legislation, as well as data collection, are required to address these issues.
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The treatment of acute ischemic stroke with recombinant tissue plasminogen activator (rtPA) has become the mainstay of treatment, but its use carries a risk of subsequent intracranial hemorrhage (ICH). Guidelines have been developed to aid in the selection of the appropriate candidates to treat with rtPA to reduce this risk. We present a case of a stroke patient who was an appropriate candidate and was treated with rtPA who experienced a fatal subarachnoid hemorrhage due to a ruptured mycotic aneurysm (MA). ⋯ A 51-year-old man presented to the Emergency Department with acute neurological symptoms concerning for acute ischemic stroke. His National Institutes of Health Stroke Scale score was 22. Emergent noncontrast head computed tomography (CT) revealed no sign of hemorrhage. The patient received intravenous rtPA, and about 1 h after the infusion was started, he had an acute deterioration in his mental status. Repeat CT scan revealed a large subarachnoid hemorrhage, and the patient was later found to have two intracranial aneurysms consistent with a ruptured MA that were related to his remote history of infective endocarditis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The majority of MAs are caused by infective endocarditis. In patients presenting with acute neurologic symptoms with a history of infective endocarditis, emergency physicians should strongly consider obtaining CT angiography to rule out MA prior to treating presumed acute ischemic stroke with rtPA.
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Hematometrocolpos caused by an imperforate hymen is a common form of vaginal outflow obstruction. This is a rare pediatric anomaly that can present with atypical or vague symptomatology, such as abdominal pain or constipation or urinary retention in the setting of amenorrhea. It is essential to obtain a gynecologic history and inquire about menstrual cycles to properly evaluate a young female with such a common complaint as abdominal pain. Failure to perform a gynecologic examination in the emergency department setting may delay diagnosis and appropriate care for this rare condition, which can lead to serious complications. ⋯ This case describes a 12-year-old female who presented to the emergency department with a complaint of abdominal pain and urinary symptoms. Because of the severity of the patient's pain on abdominal examination, we obtained a computed tomography scan of her abdomen and pelvis, which showed findings consistent with hematometrocolpos. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Obstruction of the female genital outflow tract is a rare occurrence. Because abdominal pain is such a common complaint, not only in the pediatric emergency department but also in the outpatient setting, the diagnosis of hematometrocolpos may easily go undiagnosed for months or even years. Obtaining a complete gynecologic history is key when evaluating young females with abdominal pain or urinary retention. Early detection and timely management can prevent serious complications and long-term sequelae. This patient had a successful outcome and early surgical management of her hematometrocolpos which was caused by an imperforate hymen.
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Case Reports
Delayed Onset of Atrial Fibrillation and Ventricular Tachycardia after an Automobile Lightning Strike.
Lightning strike is a rare medical emergency. The primary cause of death in lightning strike victims is immediate cardiac arrest. The mortality rate from lightning exposure can be as high as 30%, with up to 70% of patients left with significant morbidity. ⋯ An 86-year-old male was struck by lightning while driving his vehicle and crashed. On initial emergency medical services evaluation, he was asymptomatic with normal vital signs. During his transport, he lost consciousness several times and was found to be in atrial fibrillation with intermittent runs of ventricular tachycardia during the unconscious periods. In the emergency department, atrial fibrillation persisted and he experienced additional episodes of ventricular tachycardia. He was treated with i.v. amiodarone and admitted to cardiovascular intensive care unit, where he converted to a normal sinus rhythm on the amiodarone drip. He was discharged home without rhythm-control medications and did not have further episodes of dysrhythmias on follow-up visits. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Lightning strikes are one of the most common injuries suffered from natural phenomenon, and short-term mortality ordinarily depends on the cardiac effects. This case demonstrates that the cardiac effects can be multiple, delayed, and recurrent, which compels the emergency physician to be vigilant in the initial evaluation and ongoing observation of patients with lightning injuries.