J Emerg Med
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Quick Sequential Organ Failure Assessment (qSOFA) is a prognostic score for patients with sepsis. ⋯ Among ED patients admitted to an ICU, the SIRS and qSOFA criteria had comparable prognostic value for predicting in-hospital mortality. These prognostic values are similar to those reported by the Sepsis-3 guidelines for ICU encounters.
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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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Patients frequently present to the emergency department after ankle injuries, and the anterior talofibular ligament (ATFL) is commonly damaged. Musculoskeletal ultrasound (US) can help to make a rapid diagnosis. There is a paucity of literature describing techniques to image the ATFL with US, and the complex ankle anatomy and potential pitfalls make imaging challenging. ⋯ PBs are often present, have a predictable course, and may be useful to help optimize US probe positioning when assessing the ATFL.
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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.
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Case Reports
Ultrasound-Guided Femoral Nerve Blockage in A Patellar Dislocation: An Effective Technique for Emergency Physicians.
Patellar dislocation is an orthopedic emergency and its reduction can be painful. The aim of this case is to show that the ultrasound-guided femoral nerve blockage can be effectively used in the pain management of patellar reduction in the emergency department (ED). ⋯ A 21-year-old man was admitted to our ED after suffering a fall down a flight of stairs. The initial physical examination and plain radiography showed a patellar dislocation in the right knee. We performed an ultrasound-guided femoral nerve blockage to provide a pain-free and comfortable patellar reduction. To our best knowledge, there is no manuscript except an old case series about use of the ultrasound-guided femoral nerve blockage in the management of patellar reduction in the medical literature. Procedural sedation is the preferred method used for this purpose in ED, but these medications need to be closely monitored because of their potential complications, such as nausea, vomiting, allergic reactions, and respiratory depression. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound-guided femoral nerve blockage gave rapid and effective pain control without any complication during the reduction in this patient. Therefore, we suggest this technique be used for pain management during the reduction of a dislocated patella in the ED.