J Emerg Med
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Angiotensin-converting enzyme (ACE) inhibitor overdose is an uncommonly presenting toxicologic emergency. Management is primarily supportive care, but a small body of evidence exists to support naloxone for management of hypotension. ⋯ We present a case of accidental ACE inhibitor overdose. The patient took approximately 300 mg lisinopril over 48 h and presented for evaluation of syncope. He was hypotensive and unresponsive to fluids. We administered naloxone with immediate and sustained resolution in hypotension. The mechanism of action is briefly discussed. WHY SHOULD AN EMERGENCY MEDICINE PHYSICIAN BE AWARE OF THIS?: Naloxone is a rapid, low-risk, low-cost, and effective intervention for hypotension due to ACE inhibitor toxicity. It is supported by basic science research and clinical experience.
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Although appendicitis is the most common pediatric surgical emergency, the path to diagnosis remains equivocal, with utilization of imaging modalities largely institution dependent. ⋯ The negative appendectomy rates of transfer and primary patients were not significantly different despite more frequent CT use at nonpediatric facilities. It may be valuable to encourage US utilization at adult facilities given the potential to safely reduce CT use in the evaluation of suspected pediatric appendicitis.
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Case Reports
Successful Glenohumeral Shoulder Reduction With Combined Suprascapular and Axillary Nerve Block.
Anterior glenohumeral dislocation is a common injury seen in the emergency department (ED) that sometimes requires procedural sedation for manual reduction. When compared with procedural sedation for dislocation reductions, peripheral nerve blocks provide similar patient satisfaction scores but have shorter ED length of stays. In this case report, we describe the first addition of an ultrasound-guided axillary nerve block to a suprascapular nerve block for reduction of an anterior shoulder dislocation in the ED. ⋯ A 34-year-old man presented to the ED with an acute left shoulder dislocation. The patient was a fit rock climber with developed muscular build and tone. An attempt to reduce the shoulder with peripheral analgesia was unsuccessful. A combined suprascapular and axillary nerve block was performed with 0.5% bupivacaine, allowing appropriate relaxation of the patient's musculature while providing excellent pain control. The shoulder was then successfully reduced without procedural sedation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Procedural sedation for reduction of anterior shoulder dislocations is time consuming, resource intensive, and can be risky in some populations. The addition of an axillary nerve block to a suprascapular nerve block allows for more complete muscle relaxation to successfully reduce a shoulder dislocation without procedural sedation.
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Case Reports
Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban.
Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior chamber of the eye without a predisposing traumatic event. Hyphema can be associated with acute elevations in intraocular pressure in up to 30% of cases, which poses a significant risk for permanent vision loss if not quickly recognized and treated in the emergency department (ED). Anticoagulant and antiplatelet medications have been previously associated with cases of spontaneous hyphema; however, there are limited reports of hyphema with associated acute glaucoma in a patient taking a direct oral anticoagulant. Due to the limited data of reversal therapies for direct oral anticoagulants in intraocular hemorrhage, these patients pose a challenge in deciding whether to reverse anticoagulation in the ED. ⋯ We present a case of a 79-year-old man on apixaban anticoagulation therapy who presented to the ED with spontaneous painful vision loss in the right eye with associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage, and tonometry was significant for acute glaucoma. As a result, the decision was made to reverse the patient's anticoagulation with four-factor activated prothrombin complex concentrate. Why Should an Emergency Physician Be Aware of This? This case is an example of acute secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence regarding anticoagulation reversal in this setting. A second site of bleeding was identified by utilization of point-of-care ultrasound, which led to the diagnosis of a vitreous hemorrhage. This allowed for shared decision-making between the emergency physician, ophthalmologist, and patient regarding the risks and potential benefits of the reversal of anticoagulation. Ultimately, the patient decided to have his anticoagulation reversed to try and preserve vision.
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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.