J Emerg Med
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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.
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Emergency medical services (EMS) agencies with higher field termination-of-resuscitation (TOR) rates tend to have higher survival rates from out-of-hospital cardiac arrest (OHCA). Whether EMS agencies can improve survival rates through efforts to focus on resuscitation on scene and optimize TOR rates is unknown. ⋯ This study described the association between an educational intervention focusing on optimization of resuscitation on scene and OHCA process and outcome measures. Field termination has the potential to serve as a surrogate marker for aggressively treating OHCA patients on scene.
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Case Reports
Delayed Symptomatic Pulmonary Embolism Secondary to Bone Cement After Percutaneous Vertebroplasty.
Percutaneous vertebroplasty (PVP) is a common procedure performed on patients suffering from osteoporotic compression fractures. Complications of the bone cement escaping both locally as well as systemically into pulmonary circulation leading to pulmonary embolism (PE) have been reported in ≤26% of patients. ⋯ A 57-year-old woman presented to the emergency department with complaints of chest pain, fever, and cough. The patient had a history of an outpatient PVP from compression fractures of T5 and T7 performed 25 days before her presentation. She was in moderate respiratory distress and placed on bilateral positive airway pressure with improvement of her respiratory status. Laboratory results were remarkable for an elevated D-dimer, normal B-type natriuretic peptide, and decreased pH on venous blood gas. Pulmonary computed tomography angiography demonstrated bone cement PE in both the left lower lobe and a right middle lobe pulmonary artery. She was admitted to the hospital with improvement of her respiratory status with supportive treatment only. She was discharged after a 4-day hospital stay but died unexpectedly in her sleep 38 days after discharge. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: PVP is a common procedure that carries a risk of PE from bone cement embolization. Most of these events occur during the procedure, making the diagnosis obvious. However, delayed presentations from weeks to years have been reported. The emergency physician should consider bone cement embolization in the differential diagnosis in any patient with chest pain and shortness of breath that also has a history of PVP.
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Ultrasonography (US) is highly dependent on operators' skills. It is not only a matter of correct scan techniques; there are anatomical structures and variants, as well as artifacts, which can produce images difficult to interpret and which, if not properly understood, can be causes of errors. ⋯ We present possible anatomic pitfalls and artifacts that may affect correct interpretation of US images in patients with abdominal trauma and suggest how to avoid or to clarify them during the examination. Knowing their existence, their appearances, and the reasons why they are produced is important for proper use of this diagnostic technique.