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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The current state of scientific knowledge regarding communication between emergency medicine (EM) providers indicates that communication is critical to safe and effective patient care. ⋯ Our main finding of this research is that communication ensures shared awareness of patient health status, the care plan, status of plan steps and orders, and, especially, any critical changes or "surprises" regarding the health of a patient. Additionally, the research identified shared information needs; communication methods, strategies and barriers; and factors affecting successful communication, and has implications for both system and training design. Key implications for emergency nursing practice from this research are distilled in 10 'best practice' strategies for improving EM nurse-physician communication.
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Spinal epidural hematoma (SEH) after acupuncture is rare and may present with acute or subacute onset and varied symptoms, making it difficult to diagnose. This condition can mimic acute stroke, so it is vital to establish a clear diagnosis before considering thrombolytic therapy, which could be disastrous if applied inappropriately. ⋯ We describe a 52-year-old man who presented to our emergency department (ED) with acute onset of unilateral weakness of the limbs for 3.5 h immediately after receiving acupuncture at the bilateral neck and back. The acute stroke team was activated. In the ED, computer tomography angiography from the aortic arch to the head revealed spinal epidural hematoma. The patient was admitted to the ward for conservative treatment and was discharged with subtle residual symptoms of arm soreness 5 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute spinal epidural hematoma rarely presents with unilateral weakness of the limbs, mimicking a stroke. Because inappropriate thrombolysis can lead to devastating symptoms, spinal epidural hematoma should be excluded when evaluating an acute stroke patient with a history of acupuncture who is a possible candidate for thrombolytic therapy.
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Wandering spleen is defined as the localization of the spleen in the lower parts of the abdomen or the pelvic region, rather than the left upper quadrant. The torsion of wandering spleen is a rare clinical condition. ⋯ We evaluate a case diagnosed with torsion of wandering spleen and underwent splenectomy in our hospital and discuss it in light of the literature. A 26-year-old man presented to the emergency department with abdominal pain and abdominal distention. The patient was diagnosed with the torsion of wandering spleen based on computed tomography scan results. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The torsion of wandering spleen is rare in patients presenting with acute abdominal pain, but it is an important condition that should be considered in the differential diagnosis. The diagnosis of wandering spleen should be made before the development of potentially life-threatening complications. Emergency surgery should be undertaken in patients with splenic infarction.
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Eye examination in distressed young children can be challenging in a busy emergency department. A full, detailed evaluation is, however, often needed in ocular emergencies. ⋯ A 2-year-old boy presented to our pediatric emergency department with refusal to open his left eye for 1 day. Eye examination was difficult and yielded limited findings, despite analgesia and parental facilitation. Under such circumstances, this might require sedation or forcibly everting the child's eyelids for the eye evaluation. A rapid ocular point-of-care ultrasound was performed, which revealed sonographic findings suggestive of a retinoblastoma in the left eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The use of ocular point-of-care ultrasound facilitated the diagnosis of retinoblastoma in a child who was highly distressed and difficult to examine. Its use under such circumstances facilitated the patient's prompt evaluation and subsequent management.