J Emerg Med
-
As the number of coronavirus disease 2019 (COVID-19) cases increases globally, more cases of a rare COVID-19-associated disease process are being identified in the pediatric population. This syndrome is referred to as multisystem inflammatory syndrome in children (MIS-C). Clinical manifestations of the syndrome vary and include one or a combination of the following: vasodilatory shock, cardiogenic shock, Kawasaki-like disease, cytokine storming, coronary artery dilatation, and aneurysms. ⋯ This case report describes the presentation, findings, workup, and treatment for a 9-year-old boy diagnosed with MIS-C. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to recognize MIS-C, as it shares many of the same features as other disease processes, for example, Kawasaki disease and toxic shock syndrome, but has different complications if left untreated.
-
Case Reports
Point-of-Care Ultrasound Assists Diagnosis of Spontaneously Passed Common Bile Duct Stone.
Choledocholithiasis complicates approximately 10% of gallstone disease. Spontaneous stone migration out of the common bile duct (CBD) may occur in as many as 20% of choledocholithiasis cases. A decrease in CBD caliber occurs in the setting of spontaneous stone passage, but to our knowledge, this finding has not been appreciated using point-of-care ultrasound (POCUS) in the emergency medicine setting. ⋯ A 49-year-old woman presented to our Emergency Department (ED) with a complaint of epigastric pain radiating to the left shoulder. On examination she was found to have epigastric tenderness to palpation, but no guarding or rebound. POCUS demonstrated a dilated common bile duct, and her liver function tests were abnormally high. She was admitted to Medicine with concern for choledocholithiasis and plan for endoscopic retrograde cholangiopancreatography (ERCP), but her pain had resolved shortly after ED arrival. A repeat ultrasound examination demonstrated a normal-caliber common bile duct approximately 3 h after the initial scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Choledocholithiasis often requires admission and invasive testing. Using POCUS in conjunction with liver function tests and patient assessments may obviate a need for ERCP.
-
Case Reports
Mass Casualty Management After a Boiling Liquid Expanding Vapor Explosion in an Urban Area.
The catastrophic fail of a container holding a pressure-liquified gas can generate a boiling liquid expanding vapor explosion (BLEVE) with a subsequent blast wave, flying fragments, and fire or toxic gas release. ⋯ This report describes the management of a mass casualty disaster related to a BLEVE in an urban area due to a highway accident involving a tanker carrying liquified petroleum gas and a truck transporting chemical solvents. The event resulted in 158 casualties that were triaged, stabilized, and transported into the "hub" and "spoke" hospitals of the regional trauma network within 3 h and 22 min from the event by the Emergency Medical Services. The logistic complications related to the partial collapse of the highway bridge on an underlying urban road and the relative solutions adopted, as well as the application and advantages of the use of the Simple Triage and Rapid Treatment (START) algorithm in the field and the criteria adopted for the distribution of patients within the trauma network, are discussed, along with the potential pitfalls observed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: BLEVE events are rare but can be complex in both logistical management and clinical presentation of the lesions related to the event. The START algorithm is a valuable tool for rapid triage in mass casualty incidents.
-
It is challenging to detect posterior circulation strokes in patients presenting to the emergency department (ED) with acute dizziness. The current approach uses a combinatorial head-impulse, nystagmus, and test-of-skew method and is sensitive enough to differentiate central causes from peripheral ones. However, it is difficult to perform and underused. Further, magnetic resonance imaging (MRI) of the brain is not always available and can have low sensitivity for detecting posterior circulation strokes. ⋯ The BT is an easy, cheap, safe, and quick test that is feasible and sensitive to screen acutely dizzy patients for stroke in the ED.
-
Bupropion is not known to have direct serotonin agonism or inhibit serotonin reuptake. In spite of this, it has been implicated as a causative agent of serotonin syndrome. We highlight two cases of single-agent bupropion overdose that subsequently met the diagnosis of serotonin syndrome by the Hunter criteria, despite the absence of direct serotonergic agents. ⋯ This may be due to an indirect increase in activity of serotonergic cells. In these cases, bupropion overdose resulted in a clinical presentation consistent with serotonin syndrome, with the first having a temporal improvement after treatment with cyproheptadine. Physicians need to be aware of the potential serotonergic activity of bupropion for accurate assessment and treatment of this dangerous condition.