J Emerg Med
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Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. ⋯ A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.
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Hidradenitis suppurativa (HS) is a painful, chronic inflammatory skin condition. Patients experience exacerbations, leading them to present to the emergency department (ED) for incision and drainage. Direct injection of local anesthetic into these lesions is extremely painful and seldom provides adequate anesthesia. A modified method of the PECS II block can provide anesthesia to the skin of the axilla, making management of HS much less painful for the patient. We performed a bilateral modified PECS II block on a patient requiring incision and drainage of HS lesions in both axillae. She subsequently required no local anesthetic for the procedure. ⋯ A modified technique of the PECS II block, in which only the second injection is performed, is a potentially effective method for anesthetizing the axilla of patients with HS prior to incision and drainage.
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Case Reports
The Great Mimicker: Secondary Syphilis-Associated Nephrotic Syndrome in an Adolescent Patient.
Syphilis is long regarded as the "great mimicker" for its variety of symptoms and clinical manifestations. Rarely, it can present with renal involvement, particularly nephrotic syndrome. This is an uncommon initial presentation, particularly in pediatrics. ⋯ We present the case of a 17-year-old male adolescent who presented to the emergency department with a chief symptom of abdominal pain. In addition, he was found to have a number of stigmata characteristic of both syphilis and nephrotic syndrome, including a rash and diffuse edema, particularly in the lower extremities. This led to the diagnosis of nephrotic syndrome secondary to syphilis infection. Prompt diagnosis and treatment of syphilis resulted in resolution of both kidney injury and symptoms of the underlying infection. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the variety of manifestations of sexually transmitted infections, particularly in the pediatric population. It demonstrates how identifying syphilis as the inciting event led to the correct treatment management for the patient. This presentation serves to teach and remind emergency physicians of the wide-ranging presentations for sexually transmitted infections, particularly syphilis, and the necessity of obtaining a sexual history even in adolescent patients.
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A 49-year-old male with history of intravenous drug use presented to the Emergency Department with localized right arm swelling that has been slowly growing for months. On physical exam, there was a golf ball sized mass in the right antecubital fossa without overlying skin changes and no neurovascular deficits in the distal extremity. Point-of-care ultrasound (POCUS) was performed utilizing a water bath with visualization of bidirectional swirling in a round cavity adjacent to the brachial artery. ⋯ On color doppler ultrasound, pseudoaneurysm is characterized by the pathognomonic "yin-yang" sign. In the case of the 49-year-old male with a right antecubital mass and history of IVDU, the proposed mechanism of injury was trauma to the arterial wall secondary to auto-injection. POCUS has been found to improve identification of abscesses and its incorporation in patient evaluation can guide clinical management, prevent unwanted iatrogenic exsanguination, and determine whether there is a need for urgent vascular surgery intervention, particularly in high-risk patients.
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The need for a stronger evidence-base in paramedicine has precipitated a rapid development of prehospital research agendas. Paramedics are increasingly involved in research, leading to changes in their role. Yet, the integration of research responsibilities has proven to be challenging, resulting in varying attitudes and levels of engagement. ⋯ Research was highly valued when links to patient benefit were obvious, however, this review highlights some cultural resistance to research, particularly regarding informed consent and changes to standard practice. Paramedic research methods training should provide structured opportunities to explore concerns and emphasize the role of research in developing a high-quality evidence base to underpin safe practice. Currently, there is inadequate organizational support for paramedics to engage effectively in research activity, with minimal allocations of time, training, and remuneration. Without properly integrating research activity into the paramedic role, their capacity to engage with research activity is limited.