J Emerg Med
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The COVID-19 pandemic significantly disrupted emergency medicine residents' education. Early in the pandemic, many facilities lacked adequate personal protective equipment (PPE), and intubation was considered particularly high risk for transmission to physicians, leading hospitals to limit the number of individuals present during the procedure. This posed difficulties for residents and academic faculty, as opportunities to perform endotracheal intubation during residency are limited, but patients with COVID-19 requiring intubation are unstable and have difficult airways. Case Scenario: When PPE is being rationed, who should be the one to perform an intubation on a patient with respiratory failure from severe COVID-19? ⋯ There exist compelling motivations for involving senior residents and attendings in high-risk intubations during the COVID-19 pandemic. A just strategy will preserve residents' role whenever possible, while maximizing supervision and providing alternative routes for intubation practice.
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Case Reports
Baclofen Withdrawal With Reversible Posterior Leukoencephalopathy Syndrome: Bacterial Meningitis Mimicker.
The intrathecal baclofen (ITB) pump is an effective treatment for patients with spasticity unresponsive to oral medication. ⋯ A 31-year-old woman with spinal cord injury sequelae was admitted to the emergency department due to sudden headache and excessive confusion. The patient was on ITB for lower limb spasticity. On presentation, her vital signs revealed blood pressure of 171/106 mm Hg, heart rate of 141 beats/min, and temperature of 39.0°C. Antibiotics were promptly administered intravenously for suspicion of bacterial meningitis. Based on magnetic resonance imaging and cerebrospinal fluid findings, as well as clinical signs such as marked lower limb spasticity, the final diagnosis was determined to be baclofen withdrawal syndrome complicated by reversible posterior leukoencephalopathy syndrome (RPLS). Improved consciousness was quickly achieved on blood pressure control. Resolution of spasticity was achieved after intravenous midazolam and intrathecal baclofen via lumbar puncture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Baclofen withdrawal syndrome is the leading differential diagnosis for impaired consciousness and fever among patients using ITB pumps. Moreover, baclofen withdrawal syndrome mimics a wide variety of conditions, including sepsis. This unique case was complicated by intrathecal baclofen withdrawal syndrome coexisting with RPLS, thus presenting more similarly to bacterial meningitis than the usual baclofen withdrawal, due to marked headache, altered consciousness, and generalized convulsive symptoms. In addition to general withdrawal management, commencement of antihypertensive therapy for RPLS may have an immediate effect on the improvement of impaired consciousness.
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The new high-sensitivity cardiac troponin T (hs-cTnT) is now widely used in the United States. ⋯ Among patients with RO-ACS, hs-cTnT implementation resulted in increased rates of direct home discharge from the ED, without a significant increase in postdischarge mortality. Among patients presenting with O-CV indication, hs-cTnT implementation resulted in increased rates of cardiac testing procedures without an effect of ED discharge rates or long-term mortality.
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Traumatic asphyxia is a syndrome caused by a sudden pressure rise in the chest caused by crushing injury of the thorax or upper abdomen. It is associated with a variety of thoracic injuries, neurological symptoms, and ocular complications. ⋯ We report an unusual case of traumatic asphyxia complicated by severe, sight-threatening, elevation in intraocular pressure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: After initial stabilization, the treatment of patients with traumatic asphyxia is supportive and is mainly directed toward the accompanying injuries and complications. A complete and prompt ophthalmologic examination, including tonometry, should be an integral part of the secondary survey. This is particularly important in patients who cannot report visual impairment, such as children or unconscious patients.
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One in four older adults in the Emergency Department (ED) suffers from severe cognitive impairment, creating great difficulty for the emergency physicians who determine the urgency of their patients' condition, which informs decisions regarding discharge or hospitalization. ⋯ High MSI scores were associated with high mortality rates and longer hospitalization duration for patients diagnosed with dementia who were > 65 years old. We suggest performing prospective studies utilizing the MSI score as an indicator in ED triage settings to classify patients with dementia by their severity of risk, to determine if this benefits health, minimizes expenses, and prevents unnecessary hospitalizations.