J Emerg Med
-
Review Case Reports
Carotid Blowout Syndrome in the Emergency Department: A Case Report and Review of the Literature.
Carotid blowout syndrome (CBS) is an infrequent but dangerous oncologic emergency that must be recognized due to a mortality rate that approaches 40% and neurologic morbidity that approaches 60%. Patients present with a variety of symptoms ranging from asymptomatic to frank hemorrhage, and appropriate recognition and management may improve their outcomes. ⋯ A man in his late 60s with squamous cell carcinoma of the oropharynx presented to the emergency department (ED) with hemoptysis and several episodes of post-tussive emesis with large clots. He had been cancer free for multiple years after treatment with chemotherapy and radiation to the neck. Evaluation revealed a necrotic tumor on the posterior pharynx on bedside laryngoscopy and an external carotid pseudoaneurysm that was stented by interventional radiology. The patient experienced recurrent hemorrhage several months later and opted for palliative measures and expired of massive hemorrhage in the ED on a subsequent visit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CBS can be fatal, and early suspicion and recognition are key to ensure that a threatened or impending carotid blowout are appropriately managed. Once carotid blowout is suspected, early resuscitation and consultation with interventional radiology and vascular surgery is warranted.
-
Patients often present to the emergency department with paroxysmal atrial fibrillation. There is increasing recognition that, in a subset of patients, certain clinical triggers mediated via the autonomic nervous system may precipitate episodes of atrial fibrillation. Although identification of these triggers may be critical for prevention of future episodes, they may be overlooked by treating physicians. ⋯ We describe an otherwise healthy 64-year-old physician who presented on two separate occasions to the emergency department with atrial fibrillation. He was electrically cardioverted successfully into normal sinus rhythm and discharged without medications both times. The patient ultimately recognized that both episodes occurred in the setting of strenuous exercise followed soon after by ingestion of cold water. Since avoiding this sequence he has not had any episodes of atrial fibrillation in the ensuing 7 years. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians often encounter patients who present with paroxysmal atrial fibrillation, some of whom may have autonomic triggers or trigger sequences that precipitated it. Although our single case report cannot prove that the sequence described caused the atrial fibrillation, we hope the case can serve to highlight the increasing awareness that, in a subset of patients with paroxysmal atrial fibrillation, identification of specific triggers could be critical in prevention and should be sought.
-
The differentiation of myocardial infarction (MI) in the setting of acute heart failure (AHF) can be challenging because the majority of patients presenting with AHF show elevations of high-sensitive troponin (hs-Tn). Fast identification of MI is crucial to perform timely coronary angiography and to improve clinical outcome. ⋯ Hs-TnT-based identification of type 1 MI in patients with AHF requires higher cut-offs compared with the 99th percentile URL used in overall acute coronary syndrome populations. However, the adjusted cut-off provided only moderate sensitivity and specificity.
-
Completing an emergency medicine (EM) away rotation is integral to matching successfully into an EM residency program. The demand for EM away rotations (ARs) drives students to submit numerous applications without evidence-based recommendations to guide stakeholders on the approach or number to submit. ⋯ This study showed that, as a whole, students received one away rotation offer for every four to five applications submitted. It clarified factors contributing to increased EM away rotation application submissions and associated stressors inherent in the application experience. Our findings offer insights to inform advising recommendations. They also suggest that stakeholders consider standardizing the process and improve communication over spot availability and application status.