J Emerg Med
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Hemobilia refers to bleeding in the biliary tract, commonly due to iatrogenic, traumatic, and neoplastic causes. It is a rare source of upper gastrointestinal hemorrhage, but it can be severe and fatal. However, gallstones account for 5%-15% of hemobilia cases. ⋯ A 60-year-old woman with diabetes mellitus and chronic kidney disease visited the emergency department with complaints of epigastric pain and vomiting of coffee ground-like content for 2 days. Physical examination revealed epigastric tenderness and hyperactive bowel sounds. Laboratory tests showed anemia with a hemoglobin count of 10.7 mg/dL and elevated liver function tests with total and direct bilirubin levels of 3.6 mg/dL and 2.5 mg/dL, respectively. Panendoscopy showed oozing of coffee ground-like material at the orifice of the ampulla of Vater and second portion of the duodenum, leading to suspicion of hemobilia. After admission, endoscopic retrograde cholangiopancreatography revealed common bile duct (CBD) dilatation with choledocholithiasis, biliary sludge, and filling defect at the middle section of the CBD. Endoscopic sphincterotomy with balloon lithotripsy was performed. After biliary decompression and broad-spectrum antibiotic administration, abdominal pain was relieved, and liver enzyme and total bilirubin levels improved. Symptoms of hemobilia depend on the bleeding rate and presence of bile duct obstructions due to clots. Minor and slow bleeding tend to form clots and cause biliary obstruction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although minor hemobilia may remain asymptomatic and tends to resolve spontaneously, the cause of hemobilia must be corrected to prevent recurrent bleeding or obstruction.
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Diagnosing pneumonia and other lung conditions can be challenging in patients with severe intellectual or physical disabilities or severe chest deformities. Physical examination is sometimes difficult to perform and the frequently requested chest x-ray (CXR) study is often of little value in the diagnostic approach to this population. Point-of-care lung ultrasound (US) is an emerging diagnostic tool with particularly high level of accuracy in detecting pneumonia, pleural effusion, and pneumothorax. ⋯ This case series describes four cases demonstrating the usefulness of point-of-care US in a pediatric emergency department for lung assessment in patients for differentiation and diagnosis of acute causes of acute respiratory symptoms, in whom clinical features or CXR failed to confirm or exclude pulmonary complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients with chest deformities, pulmonary complications can be disproportionately frequent. Lung US should be recognized as an important adjunctive tool in this subset of patients to detect pneumonia, pleural effusions, and pneumothorax. When used proactively, it can reduce unnecessary radiation exposure, provide more certainty in determining the diagnosis, and, most importantly, inform correct and timely management.
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Occlusive abdominal aortic thrombus is a rare but critical clinical emergency with life-threatening consequences. Clinical presentation may mimic other diagnoses, resulting in a delay in the appropriate investigations for this condition. Spinal arterial involvement is a recognized complication of aortic thrombus and can result in pain, lower limb weakness, and loss of continence. These symptoms are usually associated with local spinal compression or stenosis manifesting as cauda equina syndrome (CES): a clinical finding of disrupted motor and sensory function to the lower extremities and bladder. ⋯ We present a case of a 60-year-old female patient presenting with back pain, leg weakness, paresthesia, and urinary incontinence. She was urgently investigated for cauda equina syndrome via a magnetic resonance imaging scan of the spine, which subsequently demonstrated a large occlusive abdominal aortic thrombus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nontraumatic acute thrombosis of the aorta is a life-threatening condition that may present with apparent neurological symptoms. In this patient there was both a relevant history and evolving clinical signs pointing toward a vascular etiology; however, the clinical findings were confusing and CES evaluation was prioritized. CES remains a medical emergency requiring urgent investigation and management. However, knowledge of spinal anatomy including vascular supply may help widen the differential. Physicians and associate specialists should consider this at clinical assessment and also when interpreting imaging of the spine. Any delay in diagnosing an aortic thrombosis has the potential for catastrophic clinical consequences.
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Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments. ⋯ A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.
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Delayed care in emergency departments (EDs) is a serious problem in the United States. Patient wait time is considered a critical measure of delayed care in EDs. Several strategies have been employed by EDs to reduce wait time, including implementation of self-check-in kiosks. However, the effect of kiosks on wait time in EDs is understudied. ⋯ Self-check-in kiosks are associated with shorter ED wait time in the United States. However, prolonged ED wait time continues to be a system-wide problem, and warrants multilayered interventions to address this challenge for those who are in acute need of immediate care.