J Emerg Med
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Severe sepsis and septic shock are potentially deadly conditions managed in the emergency department (ED). Management centers on source control, fluid resuscitation, broad-spectrum antimicrobials, and vasopressors as needed. The use of corticosteroids is controversial. ⋯ Septic shock is associated with higher mortality, specifically for patients with vasopressor and fluid-refractory shock. The use of physiologic-dose steroids can reduce vasopressor requirements and improve time of shock resolution. Current literature suggests corticosteroids do not improve mortality, but further studies are required.
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Changes in the manner in which medications can be delivered can have significant effects on the quality of care in the acute care setting. ⋯ INF is associated with improved timeliness and equivalent effectiveness and safety when compared to IVO in the setting of the pediatric ED.
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Case Reports
Spontaneous Subclavian Artery Dissection Causing Ischemia of the Medulla Oblongata and Cerebellum.
Spontaneous subclavian artery dissection is a rare etiology. Spontaneous artery dissection causing brain ischemia is rare in all ischemic strokes. However, in young to middle-aged patients with brain ischemia, spontaneous carotid or vertebral artery dissection causing ischemic stroke accounts for 10-25%. ⋯ A 58-year-old man with a history of hypertension presented to the Emergency Department with a sudden onset of left-arm paresthesia and numbness followed by symptoms of vertigo and vomiting. A neurological examination showed left-arm paresthesia, horizontal-rotational nystagmus, and left-side dysmetria according to a finger-to-nose test. Contrast-enhanced computed tomography showed left subclavian artery dissection. Diffusion-weighted imaging demonstrated hyperintensity in the left medulla oblongata and inferior part of the cerebellum. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous artery dissection is an important etiology of ischemic stroke among young patients. Cervical magnetic resonance angiography is the gold standard for the diagnosis of arterial dissection. Cervical disc disease is a common etiology in a patient with neck and shoulder pain without cause or neurologic symptoms, when cervical MRI is negative, however, spontaneous subclavian artery dissection should be considered in the differential diagnosis when a patient, especially in a case of younger patient, presents with acute new-onset neck and shoulder pain followed by the onset of neurological symptoms.
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Case Reports
Intractable Nausea Due to the Area Postrema Syndrome of Neuromyelitis Optica: An Uncommon Cause of a Common Symptom.
Nausea and vomiting are common emergency department (ED) complaints. Neuromyelitis optica, a demyelinating disorder, has a predilection for the area postrema, the central nausea and vomiting center. Demyelinating lesions in this region cause intractable nausea and vomiting. ⋯ We present a case of area postrema syndrome due to neuromyelitis optica in a 34-year-old woman who was seen in several EDs before the appropriate diagnosis was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nausea and vomiting are complaints that commonly bring people to the ED, thus, emergency physicians are likely to be the first to encounter and diagnose the area postrema syndrome.
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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.