J Emerg Med
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Case Reports
Intrathecal Baclofen Overdose With Paradoxical Autonomic Features Mimicking Withdrawal.
Intrathecal Baclofen (ITB) has become an increasingly common treatment for severe muscle spasticity associated with conditions such as cerebral palsy and spinal cord injury. Classically, withdrawal symptoms mimic symptoms of serotonin syndrome with hypertension, increased spasticity, clonus, hyperthermia, tachycardia, and possibly acute psychosis. Hypotension, muscle flaccidity, and respiratory depression are generally considered symptoms of toxicity or overdose. ⋯ We present the case of a male with recent ITB pump revision who presented with autonomic features suggestive of Baclofen withdrawal, while the remainder of his physical examination suggested appropriate medication dosing. Interrogation of the patient's ITB pump revealed normal function, and the patient had no clinical change with intravenous benzodiazepines, but his condition ultimately improved when his Baclofen dosing was decreased, indicating toxicity instead of withdrawal. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As Baclofen pump use increases, the importance of recognizing these potentially life-threatening complications also increases. This case presents the emergency physician with an atypical presentation and emphasizes the importance of a thorough neurologic examination to diagnose patients accurately.
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Acute aortic occlusion is a rare condition that requires early diagnosis to help prevent considerable morbidity and mortality. Typical clinical findings, such as acute lower extremity pain, acute paralysis, and absent pedal pulses, may be masked by a variety of underlying medical conditions. ⋯ We present a patient with altered mental status, hypothermia, and a large discrepancy between oral and rectal temperature measurements, who was ultimately diagnosed with aortic occlusion. This case report describes a marked difference between oral and rectal temperatures in a case of acute aortic occlusion. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute aortic occlusion is a true vascular emergency that, without early intervention, can lead to limb ischemia, bowel necrosis, paralysis, or death. Emergency physicians should consider acute aortic occlusion in a patient with a marked difference between oral and rectal temperature measurements who otherwise has a limited clinical evaluation.
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It is vital for frontline emergency physicians to immediately recognize the signs and symptoms of measles to initiate appropriate therapy and prevent spread to the health care team and other patients. ⋯ Emergency physicians must be readily able to identify, contain patients with suspected measles, and determine who will need further medical management for this potentially life-threatening illness. As this public health crisis evolves, novel ways of screening for and reporting cases of measles is needed.
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Acute pain represents one of the most common reasons for emergency department (ED) visits. In the opioid epidemic that North America faces, there is a significant demand for novel effective pain control modalities, especially in the acute setting. ⋯ ESPB is an easy-to-administer interfascial plane block that has several indications and promising potential for acute pain management in the ED. The easily identified landmarks coupled with its low complication rate makes it an appealing technique to be used by emergency physicians in the context of acute pain management. Further studies should investigate any other possible indications and compare its efficacy with other techniques, such as epidurals and serratus anterior blocks.
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Case Reports
Early Diagnosis of a Pediatric Pancreatic Tumor by Abdominal Physical Examination: A Case Report.
Detecting a neoplasm in pediatric patients with acute abdominal pain is difficult, especially when there is no palpable mass. Ihara's maneuver, which allows the physician to apply manual pressure directly on the pancreatic body, is a useful palpation method of diagnosing acute pancreatitis in children. We report a case of solid pseudopapillary neoplasm of the pancreas (SPNP) detected by Ihara's maneuver. ⋯ An otherwise healthy, 15-year-old male visited our emergency department with acute abdominal pain and nausea. His vital signs were appropriate for his age. A physical examination denied peritoneal signs, but Ihara's maneuver induced strong tenderness. His serum amylase and lipase were normal. A contrast-enhanced computed tomography scan revealed a well-defined, 2.2-cm, nonenhanced mass in the pancreatic tail. Laparoscopic distal pancreatectomy was performed, and the diagnosis of SPNP was confirmed. The patient was well postoperatively without any metastasis. SPNP is a rare neoplasm with low malignant potential. Although it typically occurs in young females, it has also been reported in children. The early diagnosis of SPNP is usually challenging because most patients do not have specific symptoms or laboratory findings. In the present case, the SPNP was difficult to detect by palpation because of its size, but Ihara's maneuver induced strong tenderness of the pancreas and led to a diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ihara's maneuver has the potential to enable early diagnosis not only of pancreatitis but also of pancreatic tumors, such as SPNP.