J Emerg Med
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Case Reports
Top of Basilar Syndrome Presenting With Hyperekplexia Initially Diagnosed as a Convulsive Status Epilepticus.
Hyperekplexia is a rare neurologic disorder characterized by pronounced startle responses to tactile or acoustic stimuli and increase tone. Acquired hyperekplexia is usually seen in brainstem pathologies and when it develops acutely it can be easily misdiagnosed as a convulsive seizure. ⋯ A 38-year-old man presented with acute onset generalized brief involuntary jerky movements and a decreased level of consciousness. He was initially diagnosed with convulsive status epilepticus for which he received multiple antiseizure medications without any improvement. Further investigations revealed abnormal oculocephalic reflex response and that his movements were in fact hyperkeplexia caused by brainstem infarction with basilar artery thrombus secondary to right vertebral artery dissection. Emergent thrombectomy was performed and he was eventually discharged to a rehabilitation facility. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware of hyperekplexia and how to differentiate it from convulsive stats epilepticus because the pathology and the emergent treatment of these 2 serious conditions are different. An underlying acquired brainstem pathology (especially basilar artery thromboembolism) should be suspected in any patient with untypical convulsive like movements along with focal neurologic signs compatible with brain stem pathology even when computed tomography imaging is normal. © 2020 Elsevier Inc.
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Case Reports
Pediatric Case of Successful Point-of-Care Ultrasound-Guided Nasogastric Tube Placement.
Nasogastric tube (NGT) placement is commonly performed in pediatric emergency care and is classically confirmed by any one of several methods, among which auscultation or aspiration and radiography comprise the currently recognized as the reference standard. Point-of-care ultrasound (POCUS) is used to confirm NGT insertion, especially in adults or prehospital patients, but reports of its use in the pediatric emergency department (ED) are still scarce. We report a case of successful POCUS-guided NGT placement in a pediatric ED. ⋯ A 3-year-old male undergoing remission therapy for acute lymphocytic leukemia presented to our ED with fever and decreased appetite. Tumor lysis syndrome was diagnosed, and endotracheal intubation was required because of the need for emergency hemodialysis for hypercalcemia. Because of difficulty in guiding the tube through the nose, ultrasound-guided placement was attempted. In the transverse view over the neck below the level of the cricoid cartilage, the 10-Fr NGT was visualized under ultrasound guidance as it passed through the esophagus. Subsequently, the entry of the NGT tip into the gastric cardia was confirmed on the subxiphoid longitudinal view. A chest radiograph confirmed the presence of the NGT in the stomach. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the utility of POCUS for NGT placement was reported in adult patients, reports of its use in pediatric cases are still few. POCUS is a real-time, noninvasive, time-saving procedure that can be a useful alternative to radiography for confirming correct NGT placement.
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Methohexital is a short-acting barbiturate used for procedural sedation in the emergency department (ED). As with other sedatives, adverse effects with methohexital include excess sedation and hypotension, but this agent can also lower the seizure threshold. We report a patient who developed a generalized seizure after administration of methohexital. ⋯ A 60-year-old man presented to the ED by ambulance with chest pain and shortness of breath. Paramedics had administered adenosine for supraventricular tachycardia without conversion before arrival to the ED. He had no history of seizures. His initial vital signs in the ED included heart rate of 189 beats/min with a supraventricular rhythm, blood pressure 137/108 mm Hg, respiration 22 breaths/min, and oxygen saturation of 98% on room air. It was decided to attempt synchronized electrical cardioversion, and methohexital 1 mg/kg (120 mg) was administered over 2 min for moderate sedation. Within 15 s of methohexital administration, the patient developed a generalized seizure that lasted for 90 s. After seizure termination, he was successfully cardioverted, returned to his previous baseline level of consciousness within 20 min, and discharged without further problems with a follow-up referral to neurology. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Methohexital is a short-acting barbiturate used for moderate sedation. Its adverse effects are unique in that it can lower the seizure threshold in some patients. Alternative agents for sedation should be considered in individuals with possible seizure disorders.
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Chilaiditi syndrome is a rare condition characterized by impaired fixation of the colon resulting in symptoms secondary to colonic interposition. It commonly presents with nonspecific abdominal pain and constipation, making clinical diagnosis difficult, especially in pregnancy. ⋯ A 29-year-old afebrile woman in the week 28 of pregnancy presented with right-sided abdominal pain and constipation. With an Alvarado score of 6, the working diagnoses were acute appendicitis and intestinal obstruction. After a normal transabdominal ultrasound, emergent abdominal magnetic resonance imaging showed abnormal fixation of hepatic flexure wedged between the falciform ligament and liver. Without clinical, laboratory, and radiologic signs of complete obstruction or colonic perforation, conservative therapy was introduced and was successful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptoms associated with Chilaiditi syndrome in pregnancy include nonspecific abdominal pain, and the correct preoperative diagnosis is difficult. The most common differential diagnoses are intestinal obstruction and acute appendicitis. It is important to diagnose Chilaiditi syndrome early because it can lead to severe complications, including intestinal obstruction, perforation, and ischemia. Therefore, in patients with right-sided abdominal pain with inconclusive transabdominal ultrasound, emergent magnetic resonance imaging leads to early diagnosis and treatment, minimizes maternal and fetal complications, avoids unnecessary explorations, and shortens the hospitalization.