J Emerg Med
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Case Reports
Enabling Donation after Cardiac Death in the Emergency Department: Overcoming Clinical, Legal, and Ethical Concerns.
In light of the growing gap between candidates for organ donation and the actual number of organs available, we present a unique case of organ donation after cardiac death. We hope to open a discussion regarding organ procurement from eligible donors in the prehospital and emergency department setting. ⋯ We believe that this case shows that donation after cardiac death from the emergency department, while resource-intensive is feasible. We recognize that in order for this to become a more attainable goal, additional resources and systems development is required.
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Focused cardiac ultrasound (FoCUS) is accurate for determining the presence of a pericardial effusion. Using FoCUS to evaluate for pericardial tamponade, however, is more involved. Many experts teach that tamponade is unlikely if the inferior vena cava (IVC) shows respiratory variation and is not distended. ⋯ A 53-year-old woman presented to the emergency department (ED) with severe orthostatic hypotension, exertional dyspnea, and hypoxia. The evaluation did not reveal an acute cardiopulmonary etiology, but FoCUS demonstrated a pericardial effusion, with several signs consistent with tamponade. The IVC, however, was not distended. She was believed to be hypovolemic, but fluid therapy provided minimal benefit. The patient's condition improved only after aspiration of the effusion. The patient's presentation was likely a "low-pressure" pericardial tamponade. Patients with this subset of tamponade often do not have significant venous congestion, but urgent pericardial aspiration is still indicated. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pericardial tamponade may not manifest with IVC plethora on ultrasound. Patients with low-pressure tamponade do not present with the most florid signs of tamponade, but they nonetheless fulfill diagnostic criteria for tamponade. If a non-plethoric IVC is used to rule out tamponade, the clinician risks delaying comprehensive echocardiography or other tests. Furthermore, the potential for deterioration to frank shock could be discounted, with inappropriate disposition and monitoring.
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Ketamine is a cyclohexamine derivative that acts as a noncompetitive N-methyl D-aspartate receptor antagonist. Its use for procedural sedation is recommended by national clinical policy. However, its immunogenic potential is not well documented. ⋯ We report a case of allergic reaction associated with the administration of intravenous ketamine for procedural sedation in a 16-year-old male. Minutes after administration, the patient developed a morbilliform, erythematous rash that extended to the upper and lower torso and resolved with intravenous diphenhydramine. It is most likely that this allergic reaction was caused by a ketamine-induced histamine release that has been described in vitro. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This is the first case report in which ketamine was used as monotherapy in the emergency department for the facilitation of procedural sedation that resulted in an allergic reaction. Supportive measures, including advanced airway procedures and hemodynamic support, may be necessary in more severe anaphylactic cases. Providers should be aware of this potential adverse effect when using ketamine for procedural sedation.
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Choroid detachment is a rare disease process that has a multitude of etiologies; usually related to recent ophthalmological surgery, eye trauma, corneal ulcers, or intraocular pressure-lowering agents. Point-of-care ocular ultrasound has high utility and accuracy in diagnosing pathology of the eye. ⋯ We present a case of a patient who presented with vision loss caused by a choroid detachment diagnosed on point-of-care ultrasound because fundoscopic examination was limited due to cataracts. Ultrasound findings based on location and appearance during both static and dynamic evaluation that help differentiate a choroid vs. a retinal detachment are also described. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Choroid detachments have a different sonographic appearance, as well as management, compared to a retinal detachment.
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Although colonoscopy is generally a safe procedure, lethal complications can occur. Colonoscopic perforation is one of the most serious complications, and it can present with various clinical symptoms and signs. Aggravating abdominal pain and free air on simple radiography are representative clinical manifestations of colonoscopic perforation. However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis. We present two cases of pneumomediastinum, pneumothorax, and subcutaneous emphysema caused by colonoscopic perforation. ⋯ A 75-year-old woman and a 65-year-old man presented with dyspnea, and facial swelling and abdominal pain, respectively. In the first case, symptoms occurred during polypectomy, whereas they occurred after polypectomy in the second case. Chest radiograph and computed tomography scans revealed pneumomediastinum, pneumothorax, and subcutaneous emphysema in the neck. During both operations, an ascending colonic subserosa filled with air bubbles was observed, and laparoscopic right hemicolectomy was performed in the first case. In the second case, after mobilization of the right colon, retroperitoneal colonic perforation was identified and primary repair was performed. The postoperative course was uneventful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases show the unusual clinical manifestations of colonoscopic perforation, which depend on the mechanism of perforation. Awareness of these less typical manifestations is crucial for prompt diagnosis and management for an emergency physician.