J Emerg Med
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Community-acquired pneumonia (CAP) causes appreciable morbidity and mortality in adults, especially in those ≥65 years of age. At hospital admission, an immediate and reliable risk assessment is necessary to detect patients with possible fatal outcome. ⋯ DC was independently associated with death from CAP in our study. As a practical consequence, DC could be useful in triage decisions. Patients with certain high risks could benefit from adjuvant treatment and special medical attention.
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A variety of plants contain cardiac glycosides. This has resulted in many of them being used to commit suicide. In southeast Asia, Cerebera odollam (pong-pong or suicide tree) is frequently used for suicidal ingestion. Seeds, or kernels, of this plant can cause hyperkalemia, heart block, and death due to the effects of its cardiac glycosides. ⋯ We describe six cases of pong-pong seed ingestion reported to US poison centers. The most common symptoms were vomiting and bradycardia. Three patients survived and three died. All patients who died had heart block, serum digoxin levels > 1.0 ng/mL, and were treated with anti-digoxin immune FAB. Anti-digoxin immune FAB may be ineffective in a large pong-pong seed ingestion. Patients ingesting pong-pong seeds who develop a potassium level > 8.0 meq/L or have a digoxin level > 1.0 ng/mL may be at a higher risk for death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The apparent ease of acquiring C. odollam seeds on the Internet makes knowledge of it important, as it can be used as a means to commit suicide. The apparent failure of digoxin immune FAB to treat toxicity from pong-pong is important, as other lifesaving techniques, such as extracorporeal membrane oxygenation, might be needed in severely toxic patients.
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Methylene blue (MB) has been advocated for the treatment of shock refractory to standard measures. MB is proposed to increase blood pressure in shock by interfering with guanylate cyclase and nitric oxide synthase (NOS) activity. Several studies have evaluated the vasoconstrictive and positive inotropic effects of MB in septic shock patients. However, there is a paucity of studies involving trauma patients. ⋯ A 4-year-old boy was hit by a truck while riding his bicycle and was treated with fluid resuscitation at the emergency department and then taken to the operating room for damage-control surgery. He had liver, diaphragm, rectal, and thoracic injuries. At the pediatric intensive care unit (PICU), he remained hypotensive despite volume, dopamine, epinephrine, and norepinephrine infusion. A dose of 0.5 mg/kg of i.v. MB was administered. During the next 2 h after MB administration, we were able to wean him off norepinephrine, and doses of epinephrine and dopamine were reduced. Ultimately, he was discharged from the PICU 13 days later in good condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Trauma patients who have experienced bleeding and survived the initial insult are still at risk of dying from continuing systemic hypoperfusion and the resultant multiple organ dysfunctions. Use of a low dose of MB as an adjuvant to treat shock might improve survival of these patients.
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Computed tomography (CT) of the chest has replaced lung scans and pulmonary angiography as the criterion standard for the diagnosis of pulmonary embolism (PE). Most of these examinations are negative for PE, but they frequently have incidental findings that may require further evaluation. ⋯ Enlarged lymph nodes and pulmonary nodules are both common incidental findings on chest CT. Each represents the potential for malignancy, and under certain conditions requires additional workup and further evaluation. The majority will be benign, even in high-risk populations. However, because of the increasing prevalence of the chest CT and the frequency with which incidental findings will be seen, it is important that the emergency physician be aware of common features and recommended subsequent evaluation.
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Anomalous coronary artery origins appear in roughly 1% of coronary angiograms, and up to 15% of syncope and sudden cardiac death events can be attributed to anomalous coronaries. Patients with an anomalous coronary artery arising from the opposite sinus may initially present with syncope and electrocardiographic findings of ischemia. ⋯ We describe a case in which an adolescent male presented with exercise-induced angina and syncope, and his initial electrocardiogram (ECG) showed diffuse ST-segment depression with ST-segment elevation in lead aVR. Cardiac catheterization revealed there was no coronary ostium in the left coronary cusp, and the left coronary artery had an anomalous origin from the right cusp. The patient received urgent left internal mammary artery-to-left anterior descending artery coronary bypass and a saphenous vein graft to the ramus intermedius. After he underwent 6 months of medical therapy with β-blockade and angiotensin-receptor blockade, his left ventricular systolic function improved to low-normal level (left ventricular ejection fraction, approximately 50%). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ST-segment elevation in lead aVR is strongly prognostic for left main or triple-vessel coronary artery disease. However, in patients who present with syncope and few other coronary artery disease risk factors, this ECG finding should be suggestive of an ischemic event caused by an anomalous left coronary artery. Early recognition of this pattern of clinical signs and ECG findings by an emergency physician could be critical for making the correct diagnosis and risk stratifying the patient for early coronary angiography and urgent surgical revascularization.