J Emerg Med
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Spilled gallstones are common during laparoscopic cholecystectomy; however, they rarely lead to postoperative complications. Perihepatic abscesses develop in < 0.1% of patients with spilled gallstones and are typically contained within the peritoneal cavity. ⋯ We present a 57-year-old man with history of cholecystectomy 2 years prior who presented with cough and flank pain and was discovered to have a perihepatic abscess invading his lung and kidney secondary to a spilled gallstone. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Although most perihepatic abscesses can be treated with percutaneous drainage and antibiotics, abscesses secondary to spilled gallstones usually require open or laparoscopic surgery to drain the abscess and retrieve the gallstone. Prompt identification of spilled gallstones in patients with intra-abdominal and intrathoracic abscesses can thereby guide disposition and decrease morbidity and mortality.
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Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation. ⋯ Patients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.
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Emergency Department (ED) overcrowding mainly due to the lack of access to inpatient beds negatively affects safety and quality of care. Implementation of ED short-stay units (EDSSUs) may help to mitigate this situation. ⋯ To date, only a few Spanish hospitals have implemented EDSSUs. Prevalent infections and exacerbation of chronic conditions are the most frequent causes for admission. Considering LOS, 30-day readmission rate and mortality, EDSSUs appear to be safe and effective and might be considered a tool to alleviate ED overcrowding.
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As increasing number of patients present to emergency departments with life threatening hemorrhages, particularly intracranial hemorrhage on anticoagulation physicians must be cognizant of the limitations of the available reversal options. Based upon the available literature, our institution formulated a reversal algorithm for patients with life-threatening bleeding on factor Xa inhibitors by administering factor eight inhibitor bypassing agent (FEIBA) 20 units/kg. ⋯ FEIBA is a treatment option in patients on a TSOA with acute intracranial hemorrhage with evidence of at least partial pharmacologic reversal of their anticoagulation status. There does not appear to be any major risk of thromboembolic complications associated with FEIBA. Much larger study sizes will be necessary to establish statically significant clinical efficacy for FEIBA use in this patient population. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency medicine physicians are first-line caretakers for patients with life threatening intracranial hemorrhages whether spontaneous or traumatic. FEIBA is a potentially safe option to reverse TSOA in this patient population.
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Carisoprodol, a centrally acting muscle relaxant with a high abuse potential, has barbiturate-like properties at the GABA-A receptor, leading to central nervous system depression and desired effects. Its tolerance and dependence has been previously demonstrated in an animal model, and withdrawal has been described in several recent case reports. Many cases can be effectively managed with a short course of benzodiazepines or antipsychotic agents. However, abrupt cessation in a patient with a history of long-term and high-dose carisoprodol abuse may result in symptoms that are more difficult for providers to treat. ⋯ We present a case of a 34-year-old man with a long history of carisoprodol abuse who was found unresponsive after having ingested 7.5 grams of carisoprodol. He was intubated and admitted to the intensive care unit. He was given propofol, dexmedetomidine, fentanyl, ketamine, lorazepam, midazolam, quetiapine, and haloperidol, some at high-dose infusions, before his agitation and ventilator asynchrony could be controlled. His improvement coincided with the addition of carisoprodol and phenobarbital to his treatment regimen. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trends show increasing emergency department presentations for drug-related disorders and treatment. This case highlights an uncommon case of carisoprodol withdrawal that may be encountered by emergency physicians, and demonstrates that benzodiazepines may not be sufficient to suppress severe withdrawal symptoms. Treatment with carisoprodol and phenobarbital provided additional benefit and can be considered in cases of severe carisoprodol withdrawal.