J Emerg Med
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We examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department (ED). ⋯ Most ED attendings were low- to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total scan volume and had a relatively low PSR. These findings suggest that sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the ED.
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Primary carnitine deficiency (PCD) is a rare but potentially life-threatening genetic disorder if left untreated. Although some patients remain asymptomatic lifelong, a few patients present with hepatic encephalopathy, hypoglycemia, cardiomyopathy, dysrhythmia, and even sudden death. ⋯ A 25-year-old woman with PCD collapsed suddenly while eating lunch. Bystander cardiopulmonary resuscitation (CPR) was performed for 8 min, with automated external defibrillation once before admission. Upon arrival at our emergency department (ED), she was unresponsive without a pulse or spontaneous breathing. The initial heart rhythm on the electrocardiogram monitor was ventricular fibrillation (VF). The medical staff continued CPR with defibrillation for sustained VF. Return of spontaneous circulation (ROSC) was achieved after a total resuscitation time of 14 min, with defibrillation twice after cardiac arrest. The heart rhythm after ROSC was atrial fibrillation, with a rapid ventricular rate initially and subsequent progression to sinus tachycardia with diffuse ST segment depression and a prolonged QT interval. Her low carnitine level was consistent with her underlying disease. Cardiac magnetic resonance imaging and sonography for detection of cardiomyopathy showed no significant findings. With carnitine supplementation for a few days, her plasma carnitine level returned to 30 μM, with no recurrence of ventricular dysrhythmia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PCD is rare but could be life-threatening, and compiling detailed histories may help emergency physicians to determine the cause of sudden cardiac death after resuscitation. This information may be used to correct potential underlying problems and prevent recurrence of the condition after treatment.
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In this case, a mobile medical ID was used to inform an off-duty clinician of highly relevant medical history when attending a pedestrian during a medical emergency. Mobile medical IDs are available on all major smartphone operating systems and provide information including, but not limited to, medical history, current medications, and allergy status. These can be accessed from lock screens, allowing access for off-duty clinicians to improve the quality of care they could provide while awaiting assistance.
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Shockwave lithotripsy (SWL) is a common procedure, which can result in rare, life-threatening complications, such as splenic rupture, perinephric hematoma, sepsis, and ureteral colic from retained stone. Being able to identify these complications can result in successful diagnosis and expedited management. ⋯ We describe the case of an 82-year-old female presenting to the emergency department (ED) for hypotension and vomiting. The patient had undergone SWL for a kidney stone earlier in the day. On initial evaluation, the patient was hypotensive and reported mild abdominal pain. Although initially evaluated and treated for presumed sepsis, thorough testing was able to diagnose splenic rupture and hemoperitoneum. Splenic rupture is a rare complication of SWL and the patient's initial symptoms of hypotension and fever, with a potential source of infection, suggested a common presentation of sepsis and made this case a unique diagnostic challenge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Diagnosis is always a challenge in the ED, due to the variability of patients that can be seen. Often times, a patient's medical and surgical history will provide guidance. For this reason, it is important to know what complications exist with outpatient procedures, how they may present, and what patient risk factors may lead to an increased incidence.
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Four-factor prothrombin complex concentrate (4F-PCC) is a blood coagulation product indicated for urgent reversal of warfarin. Currently there are no studies using 4F-PCC as a fixed dose to achieve hemostasis with warfarin as well as direct factor Xa inhibitors. ⋯ A fixed-dose regimen of approximately 2000 factor IX units of 4F-PCC may be a reasonable approach to achieve hemostasis in patients receiving warfarin or factor Xa inhibitors. Additionally, utilization of a fixed-dose regimen may lead to significant acquisition cost savings for facilities.