J Emerg Med
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Every emergency department (ED) faces both a rising tide and a revolving door of elderly patients. Unplanned short-term returns after a recent ED evaluation or hospital admission are sentinel events. Consequences include substantial functional decline, reduced health-related quality of life, and increased risk of dependency or death. Returning families, unaware of the significant likelihood of deterioration after an ED or hospital discharge, often harbor suspicions that something was missed. Literature describing the significant likelihood of functional decline in elderly patients after ED or hospital discharge is presented. Suggestions for incorporating the potential for subsequent deterioration into the evaluation of elderly ED patients and the discussions surrounding disposition decisions are included. ⋯ Currently, and for the foreseeable future, EDs are integral to predicting, identifying, and preventing functional decline in the elderly. For now, we are all Geriatric EDs.
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Methemoglobinemia and carbon monoxide poisoning are potentially life-threatening conditions that can present with nonspecific clinical features. This lack of specificity increases the probability of misdiagnosis or avoidable delays in diagnosis and management. These conditions are both treatable with antidotes of methylene blue and oxygen, respectively. Modern blood gas analyzers have the ability to measure carboxyhemoglobin (COHb) and methemoglobin (MetHb) levels without any additional resources. However, these results, although readily available from the machine used to perform the analysis, are not fully reported by some hospital clinical laboratories. ⋯ A 49-year-old male presented with shortness of breath and cyanosis after inhaling cocaine via a nasal route ("snorting"). Methemoglobinemia was not initially considered in the differential diagnosis. However, the diagnosis of methemoglobinemia was made once newly routinely reported laboratory results revealed an elevated MetHb level. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Routinely reporting MetHb and COHb levels with arterial and venous blood gas results will facilitate making the diagnoses of these infrequently diagnosed causes of hypoxia more quickly so that early treatment of these uncommon but potentially lethal conditions can be initiated promptly.
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Severe vaginal hemorrhage caused by disseminated intravascular coagulation (DIC) after dilation and evacuation is a rare but life-threatening situation that can be difficult to manage. Obtaining hemostasis in such a patient with heavy vaginal bleeding secondary to DIC can be difficult. One technique involves the use of a urinary bladder catheter inserted into the uterus that is inflated to apply pressure on the endometrium, allowing for tamponade of the bleeding. ⋯ A 36-year-old female gravida 2 para 0 at 21 weeks' gestation presented to the emergency department after being transferred from another facility for a higher level of care available at our facility, after a dilation and evacuation procedure that was indicated because of intrauterine fetal demise. The physical examination was significant for an ill-appearing female with active heavy vaginal bleeding. Resuscitation was initiated with packed red blood cells, cryoprecipitate, and platelets. Because of her thrombocytopenia, the development of DIC was suspected. Point-of-care ultrasound (POCUS) was performed and showed a thickened endometrial stripe with evidence of multiple anechoic foci, which were thought to represent intrauterine clots. To tamponade the bleeding, a 30-cc standard Foley urinary bladder catheter was placed into the uterus, using POCUS for guidance, to attempt to induce hemostasis via tamponade of the bleeding after inflation of the catheter balloon. Placement of an intrauterine urinary catheter to enable tamponade can be useful for the management of uncontrolled hemorrhage, but can be difficult to accomplish without use of POCUS for guidance. POCUS enabled us to accomplish accurate intrauterine placement of the urinary catheter and confirmation of a properly placed catheter balloon within the uterus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Menorrhagia in the emergency department can be difficult to manage, especially in the setting of DIC. Placement of an intrauterine urinary catheter can be useful in management but may be difficult for the inexperienced provider. POCUS can be used to guide the catheter into place and confirm the location once the balloon is inflated.
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Case Reports
Spontaneous Hemothorax Complicating von Recklinghausen Disease: Case Report and Treatment Algorithm.
Neurofibromatosis type 1 (NF1) is generally a benign disease but has the potential for rare and fatal complications. Vascular signs and symptoms associated with NF1 are reported in only 1-3% of patients. Pulmonary complications have been rarely described in the literature and spontaneous rupture of a major thoracic artery is, however, extremely uncommon. ⋯ We report the case of a patient with NF1 admitted to the emergency department for the management of a spontaneous life-threatening left hemothorax. The patient became hemodynamically unstable after thoracic drainage. Computed tomography angiography revealed extravasation at the level of the eighth intercostal artery. Digital angiography showed an intercostal aneurysm. Catheterization of the eighth intercostal artery was unsuccessful and an open surgery was finally performed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We highlight the importance of recognizing that patients with a benign disease like NF1 may present to the emergency department with a spontaneous life-threatening hemothorax. Immediate transfer for embolization is not always the best treatment management but thoracotomy is preferred in unstable patients.
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Case Reports
Duplicated or Ectopic Renal Collecting System in Two Adult Emergency Department Patients.
Duplicated renal collecting system is a urological anomaly often found in pediatric patients. It is less commonly diagnosed in adulthood, particularly in a pregnant patient. Many point-of-care ultrasonography users may not be aware of this diagnosis, particularly in patients in the emergency department. It is important to recognize the duplicated system because in general, patients will often have hydronephrosis in only one renal pole rather than the entire kidney, which corresponds to an unequal renal function as documented on renal nuclear medicine functional scans. As a consequence, if the sonographer only identifies one ureter and incompletely visualizes the kidney, obstruction of one of the duplicated structures may be missed. ⋯ We report 2 cases of duplicated ureter in patients in the emergency department who present with flank pain and urinary symptoms. Both patients were adult females, one pregnant, with duplicated ureter and severe right upper pole hydroureteronephrosis. The first patient was admitted for intravenous antibiotic therapy for pyelonephritis in pregnancy. The second was discharged with oral antibiotics and urgent urologic follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Duplicated ureter should be considered in patients with recurrent urinary tract infections or enuresis. Point-of-care ultrasonography users should note the differential hydronephrosis between upper and lower renal poles and may visualize duplicate or ectopic ureteronephrosis or ureterocele. Patients should be prescribed prophylactic antibiotics and have urgent urologic follow-up because the untreated condition can lead to irreversible renal damage.