J Emerg Med
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Hydrochlorothiazide (HCTZ) is a commonly prescribed sulfonamide thiazide-type diuretic medication that has been associated with rare cases of noncardiogenic pulmonary edema. ⋯ A man in his 50s with a medical history notable for hypertension was transferred to our institution for evaluation of refractory hypoxemia. After taking an initial dose of HCTZ earlier in the day, he developed progressive respiratory failure and was intubated at a referring hospital. Progressive hypoxemia and acute respiratory distress syndrome (ARDS) developed and he was transferred to our institution for extracorporeal membrane oxygenation (ECMO). Venovenous ECMO (vv-ECMO) was initiated in the Emergency Department and he was admitted to the intensive care unit. After several days of ECMO, his ARDS resolved and he was decannulated and extubated. Further history indicated that he had had two previous episodes of ARDS in the setting of HCTZ use without recognition of the inciting trigger, likely explaining his presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: One of the most commonly prescribed antihypertensives, HCTZ is associated with rare cases of pulmonary edema, which typically develop within minutes to hours of the initial dose of the medication. Although most cases resolve with supportive care, severe cases may require intubation and even vv-ECMO. The mechanism of the reaction is unknown, and affected individuals are typically able to tolerate other sulfonamide medications without issue.
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Left without being seen (LWBS) rates have become a key metric of emergency department (ED) flow, and high rates have been associated with poor patient outcomes, especially at busy urban, academic hospitals. ⋯ "Direct bedding" of ESI 2 patients may expedite care for the sickest patients, reducing potential harm to patients who might otherwise LWBS, without compromising care for patients triaged to less acute ESI levels.
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Case Reports
A Lot to Choke on: Case of Adult Epiglottitis with Concurrent Peritonsillar Abscess in a Patient with a Sore Throat.
In the winter months, one often sees a large increase in the volume of patients presenting to emergency departments with acute pharyngitis. While most cases of acute pharyngitis are benign, a rare minority can be life threatening. ⋯ We report a case of epiglottis with a concomitant peritonsillar abscess (PTA) in an adult who presented to the emergency department with a sore throat. Computed tomography (CT) scan showed epiglottitis with a developing left PTA. The patient was treated with broad-spectrum antibiotics, high-dose steroids, and underwent multiple laryngoscopies with eventual resolution of his epiglottic swelling. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case serves to highlight the importance of physical examination and CT imaging in identifying patients with pharyngitis who can benefit from additional interventions and monitoring. It is also an unusual example of the presence of two likely related upper respiratory pathologies presenting in the same patient.
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Acute pancreatitis is a frequent reason for patient presentation to the emergency department (ED) and the most common gastrointestinal disease resulting in admission. Emergency clinicians are often responsible for the diagnosis and initial management of acute pancreatitis. ⋯ Pancreatitis is a potentially deadly disease that commonly presents to most emergency departments. It is important for clinicians to be aware of the current evidence regarding the diagnosis, treatment, and disposition of these patients.
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Case Reports
Coma, Seizures, Atrioventricular Block, and Hypoglycemia in an ADB-FUBINACA Body-Packer.
Synthetic cannabinoid intoxication has become difficult to diagnose and manage in the United States, in part due to varying clinical effects within this heterogeneous group of compounds. ⋯ A 38-year-old man was admitted with altered mental status and bradycardia. He demonstrated progressive encephalopathy, seizure activity, second-degree atrioventricular block type I, respiratory failure, hypotension, hypothermia, and hypoglycemia. A computed tomography scan of the abdomen and pelvis revealed multiple packages in the patient's stomach and rectum. Multiple attempts at gastrointestinal decontamination were unsuccessful. On hospital day 8 the patient developed hypertensive emergency and was taken to the operating room for exploratory laparotomy. Twenty-two poorly wrapped packages were removed from the bowel. Postoperatively the patient demonstrated both generalized and focal seizure activity. His mental status slowly returned to baseline over the period of about 1 week and he was ultimately discharged without neurological sequelae after 1 month. Analysis of patient serum, urine, and plant matter from the packages identified cannabis and 2.N-(1-amino-3,3-dimethyl-1-oxobutan-2-yl)-1-(4-fluorobenzyl)-1H-indazole-3-carboxamide (ADB-FUBINACA). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The case presented demonstrates the suspected toxidrome associated with severe ADB-FUBINACA intoxication, including mental status depression, bradycardia, autonomic instability, seizure, hypoglycemia, and hypothermia. Although the patient had simultaneous exposure to cannabis, his constellation of symptoms is not consistent with cannabis intoxication. A previous animal model supports the potential of this specific synthetic cannabinoid to cause the reported toxidrome.