J Emerg Med
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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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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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Case Reports
Bedside Identification of Massive Pulmonary Embolism with Point-of-Care Transesophageal Echocardiography.
Pulmonary embolism can be difficult to diagnose, particularly in those who are hemodynamically unstable and cannot be imaged to confirm the diagnosis. Echocardiography can allow for rapid assessment of patients in shock, but requires adequate transthoracic windows to obtain clinically useful information. Emergency physician-performed transesophageal echocardiography (TEE) may be a useful tool when transthoracic echocardiography fails. ⋯ An 86-year-old woman presented to the emergency department after a fall at home. She rapidly decompensated in the emergency department and sustained a pulseless electrical activity cardiac arrest. Attempts made during the resuscitation to obtain transthoracic echocardiographic views to elicit the cause of the patient's cardiac arrest were unsuccessful. An emergency physician, with previous focused training in TEE, performed emergent TEE. The TEE examination rapidly revealed a dilated right ventricle and an empty, hyperdynamic left ventricle, suggestive of an unsuspected massive acute pulmonary embolism. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With continued growth and utility of point-of-care ultrasound in emergency medicine, TEE provides an attractive means to assess critically ill patients that may not otherwise be assessable.
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Massive pulmonary embolism (PE) carries significant morbidity and mortality with current standard of care modalities. ⋯ We present the case of a 63-year-old male status post abdominal surgery 2 weeks before presenting to the emergency department with a massive pulmonary embolism and subsequent acute cardiopulmonary failure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Here we describe a case of extracorporeal membrane oxygenation (ECMO) deployed in the emergency department as a bridge to embolectomy to successfully treat massive pulmonary embolism. This provided the opportunity to establish a "Code ECMO" protocol and algorithm for PE with cardiopulmonary instability so that patients can be rapidly triaged to the appropriate treatment modality.