J Emerg Med
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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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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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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.
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Diabetic ketoacidosis (DKA) is commonly complicated by mixed acid-base disorders. Therefore, patients with DKA can present with pH > 7.3 or bicarbonate > 18 mmol/L, which falls outside the values defined by the current traditional DKA criteria (pH ≤ 7.3 or bicarbonate ≤ 18 mmol/L). ⋯ DKA can present as traditional acidemic DKA, DKA with mild acidemia, and diabetic ketoalkalosis. Diabetic ketoalkalosis is a common yet easily overlooked alkalemic variant of DKA associated with mixed acid-base disorders, and a high proportion of these presentations have severe ketoacidosis and thus, require the same treatment as traditional DKA.
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Case Reports
POINT-OF-CARE ULTRASOUND FOR GUIDANCE OF CLOSED REDUCTION OF FIFTH METACARPAL NECK (BOXER'S) FRACTURE.
Ultrasound has been used previously in fracture identification, analgesia delivery, and fracture reduction for patients in the emergency department. It has not been previously described as a tool for the guidance of closed fracture reduction in fifth metacarpal neck fractures ("boxer's fractures"). ⋯ A 28-year-old man presented with hand pain and swelling after punching a wall. Point-of-care ultrasound revealed a significantly angulated fifth metacarpal fracture, which was confirmed with a subsequent hand x-ray study. After an ultrasound-guided ulnar nerve block, closed reduction was performed. Ultrasound was used to assess reduction and ensure improvement in bony angulation during the closed reduction attempts. Post-reduction x-ray study confirmed improved angulation and adequate alignment. Why Should an Emergency Physician Be Aware of This? Point-of-care ultrasound has previously had efficacy in fracture diagnosis and anesthesia delivery for fifth metacarpal fractures. Ultrasound can also be used at the bedside to assist in the determination of adequate fracture reduction when performing closed reduction of a boxer's fracture.