J Emerg Med
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Case Reports
Diagnosis of Aortic Dissection Presenting as ST-Elevation Myocardial Infarction using Point-Of-Care Ultrasound.
Aortic dissections can present with a broad spectrum of signs and symptoms, making them difficult to diagnose in the emergency department (ED). Aortic dissections can cause occlusion of the coronary arteries, mimicking an acute ST-elevation myocardial infarction (STEMI). Emergency point-of-care ultrasound (POCUS) may be a useful diagnostic tool to help differentiate aortic dissection from a primary myocardial infarction. ⋯ A 69-year-old man with no medical history presented to our ED complaining of chest pain. His electrocardiogram revealed new and dynamic ST-segment elevations consistent with a septal myocardial infarction. While the patient was being prepared for the cardiac catheterization laboratory, the treating emergency physician performed a POCUS study. The scan revealed an echogenic flap in the ascending aorta, significant aortic regurgitation, and intimal flaps in the carotid artery and abdominal aorta. The diagnosis of a type A aortic dissection was confirmed with computed tomography angiography. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Differentiating an acute STEMI from an aortic dissection can be extremely difficult in the ED. It is important not to delay reperfusion therapy for patients with a true STEMI; however, the same treatment can be lethal for patients with aortic dissection. Emergency POCUS is a fast and accessible test that has been shown to have high specificity for the diagnosis of aortic dissection in the ED. POCUS may be a useful tool to help emergency physicians diagnose aortic dissection presenting with STEMI.
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Current guidelines for the management of patients with severe sepsis and septic shock recommend crystalloids as the initial fluid solution of choice in the resuscitation of these patients. In recent years, there have been numerous studies published on the type of fluid used in the resuscitation of patients with sepsis. The primary goal of this article is to determine the preferred intravenous fluid for the resuscitation of patients with severe sepsis and septic shock. ⋯ Crystalloids are the preferred solution for the resuscitation of emergency department patients with severe sepsis and septic shock. Balanced crystalloids may improve patient-centered outcomes and should be considered as an alternative to normal saline, if available. There is strong evidence that suggests semi-synthetic colloids decrease survival and should be avoided. The role of albumin in the resuscitation of patients with severe sepsis and sepsis is uncertain.
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Research indicates patients often seek medical care within 1 year of suicide. Health care encounters are a crucial opportunity for health professionals to identify patients at highest risk and provide preventative services. ⋯ Universal SRS increased the number of people screened in the ED. However, negative SRS may not equate to reduced risk for future suicide within 1 year. Future studies might investigate targeted screening of individuals with known suicide risk factors, as well as alternatives to patient self-report of intent to self-harm for patients with mental health or substance abuse problems.
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Snakebites are common in many regions of the United States. Bites from exotic species, however, are rare. The white-lipped tree viper, Cryptelytrops (formerly Trimeresurus) albolabris, is a pit viper native to Southeast Asia. Bites are common in countries such as Myanmar, India, Thailand, Indonesia, and China. In this report, we describe an envenomation in an American viper keeper. ⋯ A healthy 28-year-old right-handed man who collects venomous snakes experienced a bite to the distal left thumb from a neonatal C. albolabris while feeding it. Upon arrival to the Emergency Department 30 min after the bite, the patient complained of significant pain and swelling that had progressed across his entire hand. He also experienced nausea, lightheadedness, mild dyspnea, and a burning sensation in his lungs. After discussing the risks and benefits, we elected to treat with five vials of Thai Red Cross Green Pit Viper antivenin. The patient was also treated with intravenous fluids, parenteral opioids, and ondansetron. He received an additional five vials due to worsening hematologic laboratory values. His laboratory tests normalized and his local findings improved significantly. He was asymptomatic at discharge and at multiple follow-up visits. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Envenomation by C. albolabris is characterized by local tissue injury and hematotoxicity. Supportive care and specific antivenom therapy comprise the management of these bites. This case reminds physicians that not all bites that present to the hospital will be from native snakes and helps direct emergency physicians to specific expertise and uncommon antivenoms.