J Emerg Med
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Focused cardiac ultrasound (FOCUS) is a vital tool to evaluate patients at the bedside, but its use can be limited by patient habitus, sonographer skill, and time to perform the examination. ⋯ In isolation, the PSLA view was highly sensitive and specific for identifying LV ejection fraction and moderate to large pericardial effusions. It was highly specific for identifying RV dilatation, but had only moderate sensitivity.
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Abnormal anatomy complicates emergency airway management. In this case, we describe definitive airway management in a critically injured emergency department (ED) patient with a history of partial tracheal resection who had a Montgomery T-tube, a type of T-shaped tracheal stent, in place at the time of the motor vehicle collision. The Montgomery T-tube is not a useful artificial airway during resuscitation, as it lacks a cuff or the necessary adapter for positive pressure ventilation. ⋯ We describe a case of a 51-year-old man who required emergency airway management after a motor vehicle collision. The patient had a Montgomery T-tube in place, which was removed with facilitation by ketamine sedation and topical anesthesia. The patient was successfully intubated through the tracheal stoma after removal of the T-tube. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must recognize the Montgomery T-tube, which resembles a standard tracheostomy tube externally, and have some understanding of how to manage a critically ill patient with this rare device in place. When a patient with a Montgomery T-tube in place requires positive pressure ventilation, the device may require emergent removal and replacement with a cuffed tracheostomy or endotracheal tube.
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Approximately two-thirds of patients discharged from an emergency department (ED) are prescribed at least one medication. Prescription clarification by outpatient pharmacies for ED patients can lead to delays for patients and added workload. ⋯ Clarification of directions for use, insurance or affordability issues, and clarification of the dose were the most common reasons that outpatient pharmacies contacted an ED regarding a prescription for a recently discharged patient.
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Case Reports
Emergency Department Diagnosis of Postprocedural Hemorrhagic Cholecystitis Utilizing Point-of-Care Ultrasoun.
Hemorrhagic cholecystitis is a rare cause of abdominal pain. Most often described in the setting of blunt abdominal trauma, anticoagulation use, coagulopathy (such as cirrhosis or renal failure), and malignancy (biliary angiosarcoma), this rare condition can be difficult to identify unless high on the differential. With point-of-care ultrasound becoming more commonplace in the emergency department (ED), this tool can be successfully used to make a timely diagnosis in the correct clinical context. ⋯ A 64-year-old man with a past medical history of paroxysmal atrial fibrillation status post ablation on rivaroxaban, myelodysplastic syndrome, nonalcoholic steatohepatitis, gastroesophageal reflux disease, clonal cytopenias of undetermined significance, hypertension, and chronic pain presented to the ED with complaints of right upper quadrant pain in the setting of a recent transjugular liver biopsy. Using point-of-care ultrasound, the patient was diagnosed with hemorrhagic cholecystitis. This is an incredibly rare entity, with 87 documented cases in the literature, only two of which are in the setting of transjugular liver biopsy. The patient was ultimately managed conservatively until he had worsening symptoms, and a laparoscopic cholecystectomy was performed. The patient tolerated the procedure well and recovered. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hemorrhagic cholecystitis is a rare pathology that can be easily recognized during point-of-care ultrasound examination. This allows for rapid diagnosis and surgical consultation to provide the patient with timely definitive management.
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Musculoskeletal pain (MSK) affects one out of three adults and is the most common source of significant long-term pain, physical disability, and under-treatment in the emergency department (ED). ⋯ We demonstrated that administration of an oral combination of VTS-Aspirin and ketamine to adult ED patients with acute MSK pain resulted in clinically significant pain relief in 80% of enrolled subjects.