J Emerg Med
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Review
An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia.
The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. ⋯ Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.
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Review Case Reports
Transperineal Ultrasound in the Diagnosis of Proctitis in the Emergency Department.
Patients with anorectal complaints commonly present to the emergency department (ED). In patients with prior history of pelvic radiation and those with risk factors for sexually transmitted infections, proctitis is frequently on the differential diagnosis. Computed tomography (CT) scans are frequently done in patients with atypical presentations and those with broader differential diagnoses. Although in cases with suspected uncomplicated proctitis, conducting a point-of-care transperineal ultrasound (TPUS) may provide sufficient data to confirm the diagnosis and ascertain a safe plan for outpatient management, thus limiting the need for CT scan, a frequent flow-limiting step in the ED. ⋯ In this article, we present a brief case series of patients presenting to the ED with anorectal complaints in whom TPUS revealed circumferential symmetric rectal wall edema and pericolonic stranding suggestive of proctitis. History and subsequent imaging further supported these diagnoses; we also briefly detail the patients' clinical course and outcomes. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We propose the use of TPUS as the screening imaging for anorectal pathologies and those with suspected proctitis to increase its use among emergency physicians. We review the main sonographic features of proctitis alongside reports from clinical cases, as well as the potential advantages of TPUS as a first-line imaging modality as compared with CT or magnetic resonance imaging. Although the complexities of anorectal anatomy can make TPUS a more difficult ultrasound modality to master, integrating TPUS into clinical practice will prove beneficial to both physician and patient.
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There are more than 100,000 cases of esophageal foreign body in the United States each year. Most cases resolve spontaneously; however, complete esophageal obstruction is a medical emergency. Patients with developmental disabilities are at high risk, because a large percentage of this population is effected by dysphagia, pica, tooth loss, or impulsive swallowing. In some cases, the diagnosis of esophageal foreign body can be made clinically, with the typical presentation including coughing, inability to tolerate secretions, drooling, vomiting, and dysphagia. In other instances, imaging is needed to confirm the diagnosis. ⋯ A nonverbal adult patient with history of mental retardation and dysphagia presented to the emergency department (ED) after a choking episode with persistent coughing. An x-ray study of the chest showed mild opacity at the left lung base and she was discharged with antibiotics. She returned to the ED that day with worsening symptoms suggestive of aspiration pneumonia. A computed tomography scan of the chest revealed numerous cylindrical objects in the esophagus, later identified as crayons. At least 28 crayons were removed via 3 endoscopies. During this time, the patient developed aspiration pneumonia, respiratory distress, and septic shock. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Delayed recognition of foreign body puts patients at risk for esophageal perforation, aspiration, airway compromise, infection, sepsis, and death. In nonverbal patients presenting with upper respiratory symptoms, it is especially important to consider esophageal foreign body in the differential diagnosis, because this group is high risk for missed diagnosis and complications secondary to the foreign body.
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Clavicular fractures are commonly encountered in the emergency department (ED). Fracture pain is usually treated with nonsteroidal anti-inflammatory drugs (NSAID) and opioids; however, both of these drug classes have potentially significant side effects that limit their use in certain patient populations. Hematoma blocks are safe and effective alternatives for pain control. ⋯ We present the case of a 39-year-old healthy man that presented to the ED with a clavicular fracture after a fall from a motorized scooter. He received minimal pain relief from hydrocodone-acetaminophen. A hematoma block was subsequently performed, with significant improvement in his pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hematoma blocks are safe and effective treatments for clavicular fracture pain in the ED without the potentially significant side effects of NSAIDs and opioids.