J Emerg Med
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Acute on chronic neuropathic pain is often refractory to analgesics and can be challenging to treat in the emergency department (ED). In addition, systemic medications such as opiates and nonsteroidal inflammatory drugs have risks, including hypotension and kidney injury, respectively. Difficulties in managing pain in patients with neuropathy can lead to prolonged ED stays, undesired admissions, and subsequent increased health care costs. ⋯ We describe the case of a 51-year-old woman who presented to the ED on two separate occasions for left forearm pain secondary to chronic ulnar neuropathy. During her first ED visit, the patient received multiple rounds of intravenous opiates and required hospital admission, which was complicated by opiate-induced hypotension. During her second visit, she underwent an ultrasound-guided ulnar nerve block performed by the emergency physician; her pain resolved and she was discharged home. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: Ultrasound-guided nerve blocks are an effective, safe, and relatively inexpensive alternative to opioids. Our case demonstrates that emergency providers may be able to perform ultrasound-guided regional anesthesia to treat an acute exacerbation of chronic neuropathic pain.
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Efficient airway management is paramount in emergency medicine. Our experience teaching tracheal intubation has consistently identified gaps in the understanding of important issues. Here we discuss the importance of the endotracheal tube (ETT) bevel in airway management. ⋯ Understanding the implications of the ETT bevel direction may significantly change the efficiency of deliberate endobronchial, nasal, and bougie/fiberscope-, and videolaryngoscope-assisted intubations, and while managing the patient with a tracheoesophageal fistula.
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Compartment syndrome is often considered in patients with long-bone fractures and soft-tissue injuries, but is not as commonly associated with a period of unconsciousness. ⋯ A 65-year-old man was brought to our emergency department (ED) because he had lost consciousness for an unknown amount of time after snorting heroin. He had severe pain in his upper right arm. Physical examination revealed right arm edema, paresthesia, tenderness, and firmness to palpation. During the ED assessment, the patient began to experience pain in his right hip to a degree exceeding examination findings. We considered compartment syndrome affecting his upper arm as well as his gluteal muscles. The patient was taken to the operating room for fasciotomy. The triceps muscle was found to be bulging out of the compartment, demonstrating advanced compartment syndrome. A posterior approach to the hip allowed the gluteal sling and the fascia to be released, eliminating tension on the gluteus medius/minimus and gluteus maximus compartments. With physical therapy, the patient regained full flexion and extension in his arm at the elbow, partial extension of his wrist, and range of motion and strength in his hip. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: If not recognized, compartment syndrome can jeopardize limb and life. It should be considered in patients experiencing inordinate pain, especially if they were found unconscious at the incident scene. Pressure-induced ischemia can impair muscle function within hours. If it is not relieved with fasciotomy, the patient can sustain irreversible functional loss.
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Fractures are common in children, and it can be difficult to distinguish unintentional injuries from child abuse. ⋯ Most children with femur fractures suspicious for abuse were ≤ 12 months old and not walking independently. Skeletal surveys identified additional fractures in 7% of children, and were useful in the forensic evaluation of non-ambulatory children ≤ 12 months old.
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Most patients transferred from a non-percutaneous coronary intervention (PCI) facility for primary PCI do not meet target reperfusion times. Direct transportation of patients with ST-elevation myocardial infarction (STEMI) from the scene by advanced life support (ALS) paramedics has been shown to improve reperfusion times and outcomes. ⋯ In our region, STEMI patients can be diagnosed accurately and transported safely on bypass to a PCI center for primary PCI while respecting target reperfusion times.