J Emerg Med
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Case Reports
Patient and Fetal Radiation-Induced Malignancy Risk From Imaging For Evaluation of Pulmonary Embolism in Pregnancy.
Imaging for diagnosis of suspected pulmonary embolism in pregnancy presents radiation concerns for patient and fetus. ⋯ Excess cancer risks for all techniques were small relative to baseline cancer risks, with CTPA techniques carrying slightly higher risk of breast cancer for the patient and ventilation perfusion techniques a higher risk of childhood leukemia.
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Interviews are an integral component of the residency selection process. Many programs use current residents as interviewers in addition to faculty. Although the reliability of interview scores between faculty members has been examined, little is known about the reliability between resident and faculty interviewers. ⋯ There was strong concordance between faculty and resident interview scores indicating reliability of EM resident scoring compared to faculty.
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Artifactual hypoglycemia is a low glucose measurement in a normoglycemic patient. Patients in a shock state or with extremity hypoperfusion can metabolize a higher proportion of the glucose in the poorly perfused tissue, and blood obtained from those tissues may have far lower glucose concentration than the blood in the central circulation. ⋯ We present the case of a 70-year-old woman with systemic sclerosis, progressive functional decline, and cool digital extremities. The initial point-of-care testing (POCT) for glucose was 55 mg/dL from her index finger, with subsequent repeated low POCT glucose reading, despite glycemic repletion and contradictory euglycemic serologic readings from her peripheral i.v. sites. Two separate POCTs were then obtained from her finger and her antecubital fossa, which had vastly different glucose readings; the latter was in congruence with her i.v. draws. The patient was diagnosed with artifactual hypoglycemia. Alternative sources of blood to avoid artifactual hypoglycemia on POCT samples are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Artifactual hypoglycemia is a rare but commonly misdiagnosed phenomenon that can occur in emergency department patients when peripheral perfusion is limited. We encourage physicians to confirm peripheral capillary results with a venous POCT or explore alternative sources of blood to avoid artificial hypoglycemia. Small absolute errors can matter when the erroneous result is hypoglycemia.
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Of the 8000-10,000 snake envenomations evaluated in U.S. emergency departments (ED) annually, approximately 1% are due to non-native snakes. We describe a 26-year-old man who was bitten by his captive black mamba (Dendroaspis polylepis) as he was packing it up for transport to another snake collector. ⋯ The patient presented to the ED 1 h after being bitten on the forearm, complaining of left arm pain, oral paresthesias, and dyspnea. His vital signs: heart rate 96 beats/min, blood pressure 167/101 mm Hg, temperature 36.7°C (97.9°F), respiratory rate 20 breaths/min, and room air oxygen saturation 100%. Two mildly tender puncture wounds without swelling or ecchymosis were found on the posterior aspect of the forearm. Over the ensuing 30 min his dyspnea worsened, and he developed objective weakness. He was intubated and placed on mechanical ventilation. He was treated with atropine 2 mg for bronchorrhea. Five vials of South African Vaccine Producers (Johannesburg, South Africa) polyvalent antivenom were administered 2.5 h post-bite and the patient was admitted to the intensive care unit. He was extubated 18 h post-envenomation and discharged the following day. He has remained asymptomatic since leaving the hospital. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The primary manifestations of D. polylepis envenomings are neurological. Initial signs may include paresthesias, dysarthria, dysphagia, and ptosis. Progressive descending paralysis leading to respiratory failure develops within 60 min. Muscarinic features are frequently observed. Cardiotoxicity and hematologic laboratory abnormalities may be present. Although pain is common, significant local tissue injury does not occur. In addition to supportive care, several non-native antivenoms are indicated for D. polylepis envenomations. Black mamba envenomings differ from the native snakebites with which U.S. physicians are familiar. Rapid, progressive neurological toxicity and muscarinic features are most common. Treatment consists of supportive care and appropriate antivenom administration.