Annals of emergency medicine
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Case Reports
A patient with a large pulmonary saddle embolus eluding both clinical gestalt and validated decision rules.
We report a patient with chest pain who was classified as having low risk for pulmonary embolism with clinical gestalt and accepted clinical decision rules. An inadvertently ordered D-dimer and abnormal result, however, led to the identification of a large saddle embolus. This case illustrates the fallibility of even well-validated decision aids and that an embolism missed by these tools is not necessarily low risk or indicative of a low clot burden.
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Case Reports
Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external cooling system.
Heatstroke is a life-threatening disease; however, no pharmacologic treatment has proven to be effective. In severe cases with multiple organ dysfunction, the mortality remains high and many patients inevitably develop permanent neurologic damage. ⋯ After treatment, the patient completely recovered, without any neurologic sequelae during 1 year of follow-up. To our knowledge, this is the first reported case of using therapeutic hypothermia in heatstroke.
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Case Reports
False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites.
Phencyclidine is one of the drugs of abuse included in qualitative urine drug screens that are frequently ordered in the emergency department despite concerns about specificity and clinical utility. Many drugs have been described to cause false-positive results for phencyclidine. ⋯ The involvement of tramadol and its active metabolite, N-desmethyltramadol, was confirmed by in vitro testing. These cases illustrate that tramadol and its metabolites can trigger a false-positive phencyclidine urine drug screen result in nonfatal cases and highlight the lack of specificity of the phencyclidine qualitative urine drug screen.
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We describe 3 patients admitted to the medical-surgical ICU in a university hospital with life-threatening cardiogenic shock after the ingestion of high doses of calcium channel blockers (8.4 g sustained-release diltiazem, 4.2 g sustained-release diltiazem, and 14.4 g slow-release verapamil). Cardiovascular failure and cardiac conduction disturbances were unresponsive to the usual therapy (eg, intravenous injection of high doses of calcium, glucagon, hyperinsulinemia-euglycemia therapy, fluid resuscitation) and to increasing doses of simultaneous infusions of adrenergic agonists. ⋯ At 2-year follow-up, patients were asymptomatic. Albumin dialysis with MARS therapy may be effective when used as a rescue procedure in patients presenting with sustained, life-threatening cardiogenic shock as a result of massive calcium channel blocker poisoning.