J Emerg Med
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Telemetry monitoring in patients with low-risk chest pain continues to be highly used despite a 2011 literature review and recommendations by the Clinical Practice Committee (CPC) of the American Academy of Emergency Medicine that did not find quality data to support its use. ⋯ No further quality data were identified to support the use of telemetry monitoring in patients with low-risk chest pains. Telemetry monitoring is unlikely to benefit patients with low-risk chest pain with a low-risk HEART Score.
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Acetazolamide is contraindicated in patients undergoing dialysis and should be used with caution in patients with chronic kidney disease (CKD). Here, we evaluate the effect of the concomitant use of aspirin by patient with CKD using acetazolamide. ⋯ A 63-year-old man with CKD and multimorbidity presented at our Emergency Department (ED) with general weakness and dyspnea for 4 days. Work-up at the ED revealed severe metabolic acidosis and hyperammonemia, which were initially considered signs of sepsis due to an elevated C-reactive protein level and pyuria. However, subsequent blood work indicated hyperchloremic acidosis with low lactate levels. After reviewing his medical history, we suspected the concomitant use of acetazolamide and aspirin as the etiology. Weakness, acidosis, and hyperammonemia were resolved after the patient discontinued acetazolamide. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Severe acidosis can be life threatening. Acetazolamide is known for causing mild metabolic acidosis, except in patients with severely impaired renal function. Here, we present a patient with mildly impaired renal function and concomitant aspirin use who developed severe metabolic acidosis and hyperammonemia after being prescribed acetazolamide. Regardless of the severity of the disease, patients with CKD should avoid taking acetazolamide concomitantly with aspirin.
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Joint arthrocentesis is a commonly performed procedure by the emergency physician (EP). Point of care ultrasound (POCUS) has demonstrated promise in identifying joint effusions and guiding arthrocentesis procedures. EP-performed talonavicular joint arthrocentesis has not been previously described in the literature. We present a case in which an isolated talonavicular joint effusion was identified and then subsequently aspirated using POCUS. ⋯ A 65-year-old man presented with atraumatic right ankle pain. On arrival, he was noted to have diffuse warmth and edema around the ankle and midfoot. POCUS was performed to evaluate for an ankle joint effusion, which was not present. The ultrasound was then moved distally, where a talonavicular joint effusion was noted. Inflammatory markers were found to be elevated. A magnetic resonance imaging scan revealed an isolated talonavicular joint effusion without additional acute findings. POCUS was then used to perform an arthrocentesis, which revealed monosodium urate crystals consistent with an initial episode of gouty arthritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS provides the EP with an efficient tool to diagnose joint effusions and guide arthrocentesis procedures. The foot is composed of several small joints where ultrasound can be particularly helpful. Similar to the ankle joint, these joints can be afflicted with pyogenic infections and crystalline arthropathies. To our knowledge, we present the first report of EP-performed talonavicular arthrocentesis guided by POCUS. The approach to this joint and technique for arthrocentesis are presented.