J Emerg Med
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Physicians tend to overestimate patients' pretest probability of having bacteremia. The low yield of blood cultures and contaminants is associated with significant financial cost, as well as increased length of stay and unnecessary antibiotic treatment. ⋯ Scoring systems using only vital signs, NEWS, and SF I showed moderate abilities in predicting bacteremia, whereas qSOFA performed poorly. Scoring systems using both vital signs and laboratory values, mSOFA and especially SF II, showed good abilities in predicting bacteremia.
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Case Reports
Decreased Clinical Toxicity and Two-Phase Elimination Kinetics Observed After Intravenous Iron Sucrose Overdose.
Management of oral iron overdoses is well-established, but there is limited literature regarding intravenous iron sucrose overdoses. Indications for administering deferoxamine after oral iron overdoses include clinical signs and symptoms of toxicity, along with a serum iron concentration ≥ 500 μg/dL. Reported signs and symptoms of iron sucrose overdose do not appear to correlate with those of oral iron overdoses. ⋯ We present a case of intravenous iron sucrose overdose in a clinically well-appearing patient with a presenting serum iron concentration that was several times higher than the usual threshold concentration for initiating deferoxamine treatment. A 21-year-old woman presented to the emergency department after an accidental intravenous iron sucrose overdose. The patient received a home infusion of 1000 mg iron sucrose, which was five times the prescribed dose. Her presenting serum iron concentration was 1799 μg/dL, with bicarbonate and anion gap both within normal limits and an unremarkable physical examination. Because she did not have evidence of severe iron toxicity, she was treated supportively and deferoxamine was not administered. Her serum iron concentration decreased below the toxic range over the next 14 h, and she was discharged home the next day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This patient was managed successfully with expectant care alone, suggesting that iron sucrose overdose has much lower toxicity than oral iron salt overdose. This discrepancy between measured iron concentrations and clinical presentation may be explained by the elimination kinetics of iron sucrose having separate redistribution and elimination phases.
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Clinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described. ⋯ A 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS.
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Case Reports
Point-of-Care Ultrasound Diagnosis of Ventricular Septal Rupture Post Myocardial Infarction: A Case Report.
Ventricular septal rupture (VSR) is a rare but life-threatening complication of ST-elevation myocardial infarction. Point-of-care ultrasound (POCUS) is a rapid, noninvasive imaging modality that is easily accessible and highly effective in diagnosing VSR in the emergency department (ED) setting. ⋯ A 73-year-old man with a history of type II diabetes mellitus and hypertension presented with complaints of intermittent chest pain for 48 h that had since become constant, associated with diaphoresis and shortness of breath. Physical examination was notable for shock and a new, grade V/VI systolic murmur. An electrocardiogram showed evidence of an inferior ST-elevation myocardial infarction (MI) with associated Q waves. POCUS revealed a large ventricular septal rupture with new ventricular septal defect and associated left-to-right shunting. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS in the ED setting is an effective and rapid tool for elucidating the etiology of various shock states. Emergency physicians should be aware of this particular case, as POCUS may help identify MI-related complications, including post-myocardial infarction VSR, that may necessitate surgical intervention as opposed to coronary reperfusion procedures.