J Emerg Med
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Pain is one of the most common reasons patients present to the emergency department (ED). Emergency physicians should be aware of the numerous opioid and nonopioid alternatives available for the treatment of pain. ⋯ Analgesia in the ED should be provided in the most safe and judicious manner, with the goals of relieving acute pain while decreasing the risk of complications and opioid dependence.
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Mental illness, substance abuse, and poverty are risk factors for violent injury, and violent injury is a risk factor for early mortality that can be attenuated through hospital-based violence intervention programs. Most of these programs focus on victims under the age of 30 years. Little is known about risk factors or long-term mortality among older victims of violent injury. ⋯ Mental illness, substance abuse, and poverty constitute a "lethal triad" that is associated with an increased risk of long-term mortality among victims of violent injury, including both younger adults and those over age 30 years. Both groups may benefit from targeted risk-reduction efforts. Emergency department visits offer an invaluable opportunity to engage these vulnerable patients.
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Esophageal food impaction is a common illness presenting to emergency departments (ED), and is frequently resistant to pharmacologic therapy. Several medications have been promoted for this indication, but so far have not proven effective. Endoscopic removal is frequently required to resolve the impaction, resulting in risks from anesthesia and the physical procedure, and in prolonged hospital stay for recovery. Oral nitroglycerin solution was recently used in two such cases and may represent a new therapeutic option. ⋯ A 49-year-old man presented to an ED with dysphagia 30 min after eating steak. He was given 0.4 mg nitroglycerin dissolved in 10 mL tap water orally, and obtained complete relief of symptoms within 2 min. A 43-year-old man with eosinophilic esophagitis and two prior food impaction episodes presented to a community ED with dysphagia and epigastric discomfort 110 min after eating steak. Five hours after symptom onset and after failure of intravenous glucagon, he was given 0.4 mg nitroglycerin sublingually, which resulted in headache but no relief in dysphagia. Twenty-nine minutes later he received 0.4 mg nitroglycerin solution, as above, with symptom resolution within 2 min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The cases presented above demonstrate close temporal relationships between administration of oral nitroglycerin solution and symptom relief. Oral nitroglycerin solution for esophageal food impaction seemed effective in these cases, but further research on this therapeutic option is warranted.
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Methemoglobinemia can be a potentially lethal condition due to the hypoxic stress placed on the body. In pregnancy, the deleterious effects can be even more catastrophic. The benefits of treatment in all patients, especially in those who are pregnant, must outweigh the inherent risks of the therapies used to treat methemoglobinemia. ⋯ We present a case of a 26-year-old Hispanic pregnant female at 30 weeks gestation presenting to the emergency department for chest pain, hypoxia, and cyanosis. She was subsequently diagnosed with methemoglobinemia, treated with methylene blue, and admitted to the intensive care unit with toxicology and obstetrics consultations. As an outpatient, the patient underwent genetic testing and was diagnosed with homozygous cytochrome b5 reductase deficiency as the etiology of the methemoglobinemia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Methemoglobinemia is a rare, potentially lethal, but treatable condition. In the setting of pregnancy, methemoglobinemia can pose a significant risk to the mother and fetus by causing acute hypoxia. Because methemoglobinemia can be acquired or congenital, treatments vary based on the etiology. Methylene blue is the mainstay treatment for symptomatic methemoglobinemia of levels > 20%. The teratogenic risks of methylene blue require risk-benefit analysis and discussion with the patient before utilization. Systemic maternal administration is theorized to be of lowest risk to the fetus. In this case, methylene blue was used safely as an emergent therapy for congenital methemoglobinemia during pregnancy.
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While transient ischemic attack and minor stroke (TIAMS) are common conditions evaluated in the emergency department (ED), there is controversy regarding the most effective and efficient strategies for managing them in the ED. Some patients are discharged after evaluation in the ED and cared for in the outpatient setting, while others remain in an observation unit without being admitted or discharged, and others experience prolonged and potentially costly inpatient admissions. ⋯ Discharge from the ED for rapid outpatient follow-up may be a safe and effective strategy for some forms of minor stroke without disabling deficit and TIA patients after careful evaluation and initial ED workup. Future research on such strategies has the potential to improve neurologic and overall patient outcomes and reduce hospital costs and ED length of stay.