J Emerg Med
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Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly. ⋯ Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.
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Various sources purport an association between lumbar puncture and brainstem herniation in patients with intracranial mass effect lesions. Several organizations and texts recommend head computed tomography (CT) prior to lumbar puncture in selected patients. ⋯ Data supporting routine head CT prior to lumbar puncture are limited. Physicians should consider selective CT for those patients at risk for intracranial mass effect lesions based on decision rules or clinical gestalt. Patients undergoing head CT must receive immediate antibiotic therapy.
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Loperamide is an over-the-counter, inexpensive, antidiarrheal opioid that can produce life-threatening toxicity at high concentrations. CASE REPORT 1: A 28-year-old man with a history of depression and substance abuse disorder (SUD) presented to the emergency department (ED) with shortness of breath and lightheadedness. He ingested large amounts of loperamide daily. ⋯ After intensive care unit admission, the patient experienced no further TdP and was discharged on HD 6. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should proceed with caution when treating patients with loperamide toxicity. Even in asymptomatic patients and drug discontinuance, obtain consultation with a medical toxicologist, promptly treat ECG abnormalities aggressively, and admit all patients for further monitoring.
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The multilevel designation system given to U.S. trauma centers has proven useful in providing injury-level-appropriate care and guiding field triage. Despite the system, patients are often transferred to Level I trauma centers for higher-level care/specialized services. ⋯ Nationally, trauma transfers do not have an increase in mortality when compared with directly admitted patients, despite a higher adjusted severity of illness and higher adjusted risk of mortality.
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The leading cause of surgical pneumoperitoneum is hollow viscus perforation, which accounts for approximately 90% of cases. A nonsurgical etiology may account for up to about 10% of the causes of pneumoperitoneum. However, a pneumoperitoneum often poses significant management dilemmas for surgeons, especially when signs of peritonitis are absent or when the cause is unknown prior to laparotomy. We present the first case of pneumoperitoneum due to inguinal laceration without viscus perforation after a traffic accident. ⋯ A 17-year-old male patient was admitted to the emergency department with a deep laceration of 7∼8 cm with bleeding in the right inguinal region after a collision with a passenger car while riding a bicycle. The abdominal examination revealed diffuse abdominal tenderness on deep palpation without peritoneal signs. A chest radiograph showed no free gas below the diaphragm. On computed tomography angiography of the aorta, subcutaneous emphysema in the right inguinal and femoral areas and free air in the peritoneal cavity were observed. There was no bowel perforation in an exploratory laparotomy, but the right femoral sheath ruptured, and exposure of the femoral vessels into the peritoneal cavity was observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A pneumoperitoneum can be caused by femoral sheath rupture without hollow viscus perforation in patients with a penetrating groin injury. Therefore, emergency physicians should not pursue solely abdominal/pelvic sources of a pneumoperitoneum in patients with a penetrating groin injury.