J Emerg Med
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Occam's razor instructs physicians to assume one single cause for multiple symptoms, whereas Hickam's dictum encourages them to suspect multiple concurrent pathologies. Although the general practice is to follow Occam's razor, occasionally Hickam's dictum reigns supreme. Here we present one such case, where the concurrent presence of two life-threatening pathologies posed clinical challenges in diagnosis and management. ⋯ Although cardiac tamponade and pulmonary embolism (PE) are known complications of malignancy, their concomitant existence is rare. Here we report a patient who presented with shortness of breath found to have both cardiac tamponade and submassive PE. Although the cardiac tamponade was initially diagnosed in the Emergency Department by bedside ultrasound and treated with pericardiocentesis, only a few hours later, when she deteriorated, the submassive PE was diagnosed, which was treated with heparin infusion and subsequently transitioned to a newer oral anticoagulant. The patient was later diagnosed as having primary breast cancer and metastatic lung adenocarcinoma. Why Should an Emergency Physician Be Aware of This? This raised unique diagnostic challenges, as both cardiac tamponade and PE present with obstructive shock. The increased right heart pressure from the PE could have paradoxically protected the patient from the tamponade effects of the pericardial effusion. Furthermore, the presence of cardiac tamponade may also mask the typical echocardiographic features of PE. The concurrent presence of two pathologies raised challenges and dilemmas in management. This case shows that physicians should maintain a high degree of suspicion of two pathologies when the patient deteriorates after the first pathology has been appropriately treated.
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Political rhetoric from the former U.S. president influences Latinx adults' feelings of safety and their decisions to seek care in the emergency department (ED). ⋯ Most parents heard statements against undocumented immigrants by the former U.S. president and most believed measures were being enacted. This rhetoric had a substantial negative impact on ULF parents in terms of safety concerns for their child and fear of accessing health care.
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This study was developed to provide insight into the effects of an i.v. opioid order set on prescribing of i.v. opioids in the emergency department (ED) for nontraumatic, unspecified abdominal pain. Research is needed in this area to catalyze more consistent and evidence-based i.v. opioid prescribing. ⋯ The restriction correlated with a decrease in i.v. opioids. Pain control was not diminished as a result of the restriction. The results of this study may be used to generate hypotheses for comparing different modes of pain management in the ED in this patient population and others. Future studies should continue to evaluate the impact of oral vs. i.v. opioids.
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Diquat is an herbicide that may cause rapid and profound systemic toxicity. It can cause multisystem organ failure, primarily via its effects on the gastrointestinal, renal, cardiovascular, and central nervous systems. Case fatality rates as high as 43% have been reported. There is a paucity of pediatric literature on diquat poisoning, and in this article, we will discuss an unfortunate pediatric case that highlights the severity of diquat toxicity. ⋯ We present the case of a child who ingested diquat, which led to multisystem organ failure and death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should be aware of this herbicide's potential for significant morbidity and mortality, especially in children, in whom small quantities can be lethal. It is important that emergency physicians are aware of the significant toxicity of diquat and provide early gastric decontamination, as it is the only proven therapeutic strategy.
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Observational Study
The Timing of Clinical Effects of Bupropion Misuse Via Insufflation Reported to a Regional Poison Center.
Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window that can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via insufflation, which added a layer of complexity with regards to the therapeutic application of the drug. This route of use created difficult decisions regarding clinical monitoring in these patients. ⋯ This report describes the clinical effects reported, and the timing of these effects, after insufflation of bupropion.