J Emerg Med
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Case Reports
Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss.
Candlenuts (Aleurites moluccana) and yellow oleander seeds (Thevetia peruviana) bear a physical resemblance to one another. Candlenuts are benign and marketed as weight loss supplements. Yellow oleander seeds, however, contain toxic cardioactive steroids; as few as 2 seeds may cause fatal poisoning. Because of their physical similarities, the potential for a lethal substitution exists. ⋯ A 63-year-old woman presented to the emergency department with vomiting after ingesting 5 of what she believed to be candlenuts that were ordered online under the colloquial name "Nuez de la India" for the purpose of weight loss. She was bradycardic (nadir pulse of 30 beats/min) and hyperkalemic (serum potassium 7.3 mEq/L). Within hours of presentation she suffered a ventricular fibrillation arrest, followed by a terminal asystolic arrest. Postmortem analyses of liver tissue and the seeds were consistent with fatal T. peruviana poisoning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: T. peruviana seeds contain toxic cardioactive steroids; their physical resemblance to candlenuts poses a risk of potentially fatal substitution. Therapy with high-dose digoxin specific immune fragments (20-30 vials) may be helpful.
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During the coronavirus disease 2019 (COVID-19) pandemic, healthcare systems in many regions of the country were being overwhelmed by large numbers of patients needing care. In this paper, we discuss use of an external emergency department (ED) site by a hospital system based in Charlotte, North Carolina to address concerns of a local surge similar to those seen around the country. ⋯ External expansion of the ED is an important strategy that can allow hospitals to accommodate potentially infectious patients while maintaining appropriate isolation and rapid throughput. Proper implementation of the right system to meet hospital-specific needs can prove effective for the healthcare system.
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The Bezold-Jarisch reflex is a depressor reflex of the heart due to the preferential distribution of vagal nerves in the inferior wall of the left ventricle. We report a case of Stanford type A acute aortic dissection, in which coronary spastic angina caused the Bezold-Jarisch reflex in the acute phase. ⋯ A 53-year-old man presented with left chest pain and cold sweating. An electrocardiogram was normal and the high-sensitivity cardiac troponin T level was negative. A diagnosis of Stanford type A acute aortic dissection was made based on computed tomography (CT); there was no evidence of ischemic heart disease on coronary CT angiogram obtained simultaneously. While waiting for emergency surgical repair, chest pain worsened, followed by bradycardia and hypotension, along with ST-segment elevations in the inferior leads, all of which were resolved by conservative treatment. During surgery, no evidence to suggest an extension of the dissection to the ostium of the right coronary artery was observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing the Bezold-Jarisch reflex because this depressor reflex may require different management than other conditions.
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Solomon Islands is a country in the South Pacific Ocean with excellent scuba diving, particularly among its remote islands that can be accessed by liveaboard dive boats. Blacktip reef sharks (Carcharhinus melanopterus) are found throughout the island nation and rarely attack humans. ⋯ We present the case of a 42-year-old man who sustained a hand laceration after being bitten by a blacktip reef shark. He underwent complex primary wound closure in an austere environment and received prophylactic antibiotics. No infection developed and he recovered fully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss our rationale in closing the wound aboard the dive boat, the choice of antibiotics, and review marine pathogens.
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Observational Study
Interleukin-6 as a Potential Predictor of Neurologic Outcomes in Cardiac Arrest Survivors Who Underwent Target Temperature Management.
Serum interleukin-6 (IL-6) is a cytokine released in response to an inflammatory stimulus or tissue injury. IL-6 levels are known to increase in patients with brain injury. ⋯ Serum IL-6 level immediately after ROSC was a highly specific and sensitive marker for the 3-month poor neurologic outcome, and may be a useful early predictive marker of neurologic outcome in OHCA survivors treated with TTM.