J Emerg Med
-
Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach. ⋯ Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.
-
Case Reports
Pseudomembranous Tracheobronchitis With Severe Tracheal Stenosis and Masked Bronchial Obstruction.
Pseudomembranous tracheobronchitis (PMTB) is a rare condition characterized by the formation of endobronchial pseudomembranes. PMTB overlaps with necrotizing tracheobronchitis or plastic bronchitis. The reported infectious etiology mainly includes invasive aspergillosis. PMTB can cause serious airway obstruction; however, urgent tracheotomy is rarely required. ⋯ A 46-year-old woman was transferred to the emergency department (ED) with a 1-week history of progressive dyspnea and cough that was preceded by fever and sore throat. She was previously healthy except for a 20-year history of mild palmoplantar pustulosis. Stridor was evident. Nasolaryngoscopy performed in the ED revealed severe tracheal stenosis caused primarily by mucosal edema and secondarily by pseudomembranes. Initially, tracheitis was considered the sole cause of dyspnea. Although she underwent urgent tracheotomy to prevent asphyxia, her respiration deteriorated progressively. Bronchoscopy revealed massive pseudomembranes obstructing the bilateral bronchi, which led to the clinical diagnosis of PMTB. Subsequent toilet bronchoscopy markedly improved her ventilation. The causative pathogen was not identified despite extensive work-up, including molecular biological testing. Histopathologic examination of the pseudomembranes revealed fibrin with abundant neutrophils, which was consistent with PMTB. Associated conditions, including immunodeficiency, were not found. Her condition improved with antibiotics and repeated toilet bronchoscopy. WHY SHOULD AN EMERGENCY PHYSICIANS BE AWARE OF THIS?: PMTB is an important differential diagnosis of airway emergencies. PMTB can present with critical edematous tracheal stenosis and masked bronchial pseudomembranous obstruction. Emergency physicians should include PMTB in the differential diagnosis in adult patients with acute central airway obstruction because it requires prompt multimodal treatment.
-
Phlegmonous gastritis (PG) is a rare and potentially fatal disease characterized by bacterial infection of the gastric wall. However, its clinical features are nonspecific, which may delay its diagnosis and treatment. ⋯ We report a case of a previously healthy 53-year-old woman with localized PG complicated by subphrenic abscess formation who was treated successfully with antibiotics and percutaneous catheter drainage. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment initiation are important to improving outcomes. Emergency physicians should consider PG a differential diagnosis of acute abdomen.
-
Case Reports
A Pounding Problem: A Case of Recurrent Headache Caused by Anti-NMDA Receptor Encephalitis.
Anti-N-methyl-d-aspartate receptor (Anti-NMDAR) encephalitis is a serious autoimmune disease in which antibody production against the NMDA receptor results in profound neurotransmitter dysregulation. Patients may present with a wide variety of symptoms, including psychosis, orofacial dyskinesias, dysautonomia, hallucinations, mental status changes, seizures, and headaches. ⋯ A previously healthy 25-year-old woman presented on several occasions to the Emergency Department with a severe pounding headache that initially responded well to treatment. She later developed signs consistent with meningoencephalitis along with altered mental status and neuropsychiatric changes. She was diagnosed with anti-NMDAR encephalitis after hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Anti-NMDAR encephalitis is an under-recognized condition with diverse presentations. Recurrent headaches that improve with treatment may be an early sign of this disorder. Anti-NMDAR encephalitis should be considered in patients with recurrent undifferentiated headaches, and an appropriate work-up should be performed. Early recognition and diagnosis of this condition is critical to optimize favorable patient outcomes, as delays to diagnosis may lead to fatalities and long-term neurologic sequelae.