J Emerg Med
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Patients with ST elevation on electrocardiogram (ECG) could have ST elevation myocardial infarction (STEMI) or pericarditis. Spodick's sign, a downsloping of the ECG baseline (the T-P segment), has been described, but not validated, as a sign of pericarditis. ⋯ Spodick's sign is statistically associated with pericarditis, but it is seen in 5% of patients with STEMI. Among other findings, ST depression, III > II, and absence of PR depression were the most discriminating.
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Acute or recurrent hip pain in adults can be a challenging presentation in the emergency department. While ultrasound is routinely used in the evaluation of pediatric patients with hip pain and a new limp, it is not commonly used for this purpose in adult emergency medicine. This case series demonstrates the clinical utility of point-of-care ultrasound (POCUS) in adult patients with acute or recurrent hip pain because performance of POCUS was the critical action that led to the identification of pathologic hip effusions in this series of adults. ⋯ This case series includes 5 patients in whom clinical suspicion existed for the presence of a hip effusion and possible septic arthritis, despite nondiagnostic radiographic findings. Ultrasound was used to detect the effusion and guide subsequent arthrocentesis, imaging, or surgical intervention. In all patients, computed tomography scans or magnetic resonance imaging scans were later used to confirm the presence of effusion. In all 5 patients (2 women and 3 men, with a mean age of 47.4 years), POCUS accurately detected the presence of hip effusion. Two of 5 synovial collections were caused by septic arthritis as confirmed by synovial fluid microbiologic examination. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case series emphasizes the clinical utility of POCUS in adult patients with acute and recurrent hip pain to detect a hip effusion, particularly in patients with significant risk factors for septic arthritis. POCUS can also be used to guide further imaging, arthrocentesis, surgical consultation, and intervention.
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Acute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection. ⋯ A 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.
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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.