J Emerg Med
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Kawasaki disease (KD) is a multisystem vasculitic disease. Coronary artery aneurysms (CAAs) are the most important and life-threatening complication of KD. Various neurologic complications have been described to occur in 1-30% of patients with KD, but peripheral facial nerve palsy (FNP) is rare (0.9%). ⋯ We describe a 5-month-old male infant who presented to us with unilateral left infranuclear FNP in the convalescent phase (day 18 of illness) of incomplete KD. The initial diagnosis was not made during the first 10 days of illness (therapeutic window for immunoglobulin treatment) as he was suspected to have hand-mouth-foot disease. We believe that both the delay in diagnosis and treatment of an atypical presentation of KD, combined with the more severe vasculitis and inflammatory burden reported in these cases, contributed to the development of CAA in our patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of considering KD diagnosis in children with prolonged unexplained fever, even with incomplete diagnostic features, as well as the need to be aware of unusual manifestations, such as FNP. Atypical cases like this may be at increased risk of CAA because of delayed diagnosis and a higher inflammatory burden; therefore, a more aggressive treatment approach may be necessary.
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Mental health conditions account for 52.8 million (4.9-6.3%) emergency department (ED) visits in the United States. Psychotic conditions are responsible for approximately 10% of all mental health presentations. ⋯ UMC is a common etiology in patients presenting to the ED with a first episode of psychotic symptoms.
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Critically ill or injured emergency department or prehospital patients who lack decision-making capacity sometimes present with a non-standard advance directive, such as a "Do Not Resuscitate" tattoo or medallion. Emergency clinicians must immediately address the question of whether to withhold treatment based on what may or may not be a valid patient directive. ⋯ Advance directives have been standardized for a good reason. Emergency department or prehospital healthcare providers must be able to immediately interpret and act on them without needing a legal interpretation. When faced with non-standard directives, physicians can follow them, ignore them, or simply use them as an additional piece of information about the individual's wishes for some situations at one point in his or her life. Absent the patient's input or that of aknowledgeable surrogate, both the patient's initial reasons for their non-standard directive and his or her present wishes concerning resuscitation cannot be independently known. Therefore, healthcare providers must initiate treatment while they buy time, attempt to return the patient to lucidity, and search for probative information regarding their current wishes concerning medical treatment. Without such additional information, the moral weight will always favor initiating treatment, since withholding treatment is often irreversible and any treatment instituted can later be withdrawn.
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Per rectum (PR) medication delivery is an alternative to traditional oral (PO), intravenous (IV), or intramuscular (IM) administration of medication for procedural sedation of pediatric emergency department patients. However, many emergency physicians are unfamiliar with its use, and there are no widely adopted guidelines or reviews dedicated to this topic. ⋯ Pediatric procedural sedation with PR medications appears to be feasible, moderately effective, and safe based on our review of the current literature. However, further studies on its applicability in the emergency department setting are needed.