J Emerg Med
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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.
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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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Observational Study
Incidental Findings on Pediatric Abdominal Computed Tomography At A Pediatric Trauma Center.
The increasing availability and use of computed tomography (CT) in pediatric abdominal trauma has increased the detection of incidental findings. While some of these findings are benign, others may require further evaluation for possible clinical importance. ⋯ Nearly one-third of patients had at least one radiographic finding unrelated to their injury. Of these, more than two-thirds did not require additional evaluation, but nearly one-third of patients required some form of further work-up.
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Case Reports
Airway Management in an Infant with a Large Supraglottic Mass after Failed Fiberoptic Intubation.
Fiberoptic bronchoscope-guided tracheal intubation is the gold standard for managing patients with supraglottic growths. In infants with a large and overhanging epiglottis, the success of fiberoptic-guided intubation relies heavily on the available space between the inferior surface of the epiglottis and the posterior pharyngeal wall or, more specifically, the superior surface of the supraglottic growth. ⋯ We describe the inability to negotiate the tip of the fiberscope between the epiglottis and the supraglottic growth and the successful use of direct laryngoscopy to improve the available space along with the usefulness of "bubbling of air" to locate the glottic opening in an infant. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We emphasize the role of the emergency physician in managing such patients. Most of the time, the setting is not ideal in such emergency situations and the most qualified clinician to treat them is the emergency physician. The knowledge and skills of the emergency physician, along with awareness of the possible techniques for airway management, can be lifesaving.
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Pneumocephalus has been described as an unintended outcome after epidural injections. However, oculomotor palsy from pneumocephalus after epidural injection is very rare. ⋯ We report a case of pneumocephalus-induced sixth nerve palsies and diplopia in an 87-year-old woman after epidural steroid injection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pneumocephalus-induced oculomotor palsy is a rare complication after epidural injection, a commonly performed medical procedure. Knowledge of this presentation will help emergency physicians distinguish between this entity and other causes of neurologic deficits.