J Emerg Med
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Viscoelastography (VE) is an established method to identify coagulopathies in various disease processes. Clinical decisions can be made with real-time tracings and quantitative values at the bedside. Thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®) have been utilized in several disease states with clinical varying success. ⋯ This review serves as a way for emergency medicine clinicians to utilize VE in their practice and provides an insightful literature overview.
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Kounis syndrome is a rare condition that is characterized by the coexistence of acute coronary syndrome and allergic reactions; however, its time course remains unclear. We report a case of anaphylactic shock with subsequent development of ST-segment elevation myocardial infarction. ⋯ A 47-year-old man with food allergies presented to the emergency department of our hospital with breathing difficulties after eating bread. He had a history of angina and underwent stent implantation 3 years earlier. On examination, he was lethargic, disoriented, and in shock. He had a rash on his face and anterior chest wall, as well as severe itching and sweating. Anaphylaxis was diagnosed and, 3 min after presentation, 0.5 mg epinephrine was injected intramuscularly into the right thigh. Electrocardiography, which was recorded 2 min after the administration of epinephrine, was normal; however, chest pain developed suddenly 18 min later. Repeat electrocardiography showed ST-segment elevations, and emergency coronary angiography revealed total occlusion of the left anterior descending coronary artery (i.e., the previous stenting site). Recanalization of the left anterior descending coronary artery was achieved after repeated thrombus aspiration with difficulty, followed by stent implantation inside of the stent under the support of intra-aortic balloon pumping. The clinical course was uneventful. He was discharged and advised to avoid eating wheat and carry an epinephrine self-injection kit for anaphylaxis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The present case highlights the importance of recognizing Kounis syndrome in the management of anaphylactic shock because treatment may be difficult, particularly in patients with type III Kounis syndrome.
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Perfusion index (PI) derived from pulse oximeter shows the ratio of the pulsatile blood flow to the nonpulsatile blood flow or static blood in peripheral tissue. ⋯ PI might be beneficial in the detection and exclusion of critical patients and blood transfusion needs in the emergency department. PI can be used with vital signs and shock parameters in the early diagnosis of hemorrhage.
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Eighty-eight percent of pediatric emergency department (ED) visits occur in general EDs. Exposure to critically ill children during emergency medicine (EM) training has not been well described. ⋯ Pediatric critical care exposure during EM training is very limited. These findings underscore the importance of monitoring trainees' case experience to inform program-specific curricula and to develop strategies to increase exposure and resident entrustment, as well as further research in this area.
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Cardiac tamponade is a life-threatening disease with a high mortality rate. Its clinical manifestations depend on the length of time over which pericardial effusion accumulates. Among those, hiccups are rarely reported. ⋯ We present a 48-year-old man who came in with a chief complaint of persistent hiccups and later had hypotension and dyspnea at the emergency department. Electrocardiogram revealed diffuse ST elevation with mildly elevated cardiac enzymes. Echocardiography showed massive pericardial effusion, implying cardiac tamponade. Catheter pericardiocentesis was performed and massive pericardial effusion was drained. Hiccups subsided after the procedure and the patient recovered uneventfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To the best of our knowledge, this is the first case of cardiac tamponade with the presenting manifestation of persistent hiccups. Emergency physicians should stay vigilant when approaching those patients with unexplainable prolonged hiccups.