J Emerg Med
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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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Shotguns represent a distinct form of ballistic injury because of projectile scatter and variable penetration. Due in part to their rarity, existing literature on shotgun injuries is scarce. ⋯ In the United States, shotgun wounds are an infrequent mechanism of injury. Shotgun wounds as a result of interpersonal violence far outweigh self-inflicted and accidental injuries. White men in their 20s in the southern parts of the country are most commonly affected and thereby delineate the high-risk patient population for injury by this mechanism at a national level.
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Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. ⋯ Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.
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Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning. ⋯ These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.
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Case Reports
Tracheal Irrigation Without Bronchoscopy as an Alternative Emergent Treatment of Blood Aspiration.
Tracheobronchial foreign body aspiration can cause mild symptoms but may also become dangerous enough to cause death. Bronchoscopy is the first choice for the diagnosis and the removal of aspirated foreign bodies. So, when bronchoscopy is not available, the situation might get challenging. ⋯ A 62-year-old man was waiting for emergent surgery for traumatic epidural hematoma in the Emergency Department (ED). Endotracheal intubation was performed for surgery and airway maintenance. However, oxygen saturation dropped and respiratory arrest was expected. As emergent bronchoscopy could not be performed, the emergency physician decided to irrigate the trachea by using 0.9% normal saline in the ED. After three rounds of irrigation, vital signs including oxygen saturation improved and the patient could undergo neurosurgical surgery. The patient was subsequently discharged with improved health. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bronchoscopy is the first choice for the treatment and diagnosis in cases of bronchial aspiration of blood, such as that caused by epistaxis. However, in emergency situations, such as deteriorating vital signs due to aspiration of life-threatening amounts of blood from epistaxis, using blind tracheal irrigation as an alternative tool when bronchoscopy is not available can help in achieving clinically acceptable results.