The American journal of emergency medicine
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The Thrombolysis in Myocardial Infarction (TIMI) risk score is a validated risk stratification tool useful in patients with definite and potential acute coronary syndromes (ACS) but does not identify patients safe for discharge from the emergency department (ED). Likewise, the use of a clear-cut alternative noncardiac diagnosis risk stratifies patients but does not identify a group safe for discharge. We hypothesized that the presence of an alternative diagnosis in patients with a TIMI risk score less than 2 might identify a cohort of patients safe for ED discharge. ⋯ The TIMI risk score stratifies patients with and without an alternative diagnosis. Unfortunately, patients with both a low TIMI risk score and a clinical impression of an alternative noncardiac diagnosis still have a risk of 30-day adverse events that is not low enough to allow safe discharge from the ED.
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Case Reports
Pseudoaneurysm of the anterior tibial artery detected by emergency medicine physician performing bedside ultrasound.
We present the case of an anterior tibial artery pseudoaneurysm secondary to lacerating trauma caused by a straight-edge trimming blade. A 56-year-old man presented to emergency department (ED) with 1-month history of left calf pain. Thirty days before presentation, the patient lacerated his left lateral pretibial area with a cutting blade--similar to a machete--while cutting grass. ⋯ Doppler US of the patient showed 4.5x2.5-cm partially thrombosed pseudoaneurysm of the anterior tibial artery. In this case, the pseudoaneurysm was believed to be compressing the posterior tibial artery, resulting in a diminished pulse on examination. Emergency US use may enhance emergency physician performance by the shortening of the length of stay in the ED, reduce the number of unnecessary tests to be ordered, and hasten critical therapeutic interventions.
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Cardiac multidetector computed tomography (CMCT) has potential to be used as a screening test for patients with acute chest pain, but several tools are already used to risk-stratify this population. Risk models exist that stratify need for intensive care (Goldman), short-term prognosis (Thrombolysis in Myocardial Infarction, TIMI), and 1-year events (Sanchis). We applied these cardiovascular risk models to candidates for CMCT and assessed sensitivity for prediction of in-hospital acute coronary syndrome (ACS). We hypothesized that none of the models would achieve a sensitivity of 90% or greater, thereby justifying use of CMCT in patients with acute chest pain. ⋯ Available risk scores had poor sensitivity to detect ACS in patients with acute chest pain. Because of the small number of patients in this data set, these findings require confirmation in larger studies.
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Case Reports
Traumatic vertebral artery dissection and Wallenberg syndrome after a motorcycle collision.
Wallenberg syndrome is also called lateral medullary syndrome or posterior inferior cerebellar artery syndrome. The clinical presentations include ipsilateral Horner syndrome, ipsilateral cerebellar signs, and the hypalgesia of ipsilateral face and contralateral body. A considerable number of cases of Wallenberg syndrome were reported to be associated with vertebral artery dissection (VAD). ⋯ Overall, most cases have good prognosis. However, the rarity and various presentations of VAD may challenge emergency physicians in making correct diagnosis in the emergency department. Hence, maintaining a high index of suspicion is needed for an early diagnosis, especially in young people without risk factors attributing to cerebrovascular accident.
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Case Reports
First-order alcohol elimination in severe alcohol intoxication in an adolescent: a case report.
We report a case of severe ethanol intoxications in a 14-year-old boy whose starting blood alcohol concentration was 490 mg/dL. The intoxication led to coma with hypoventilation, hypoxemia, hypothermia, and a life-threatening situation. ⋯ Fluid balance was disturbed because of marked diuresis, and respirator treatment was needed. The treatment of fluid balance and the risk of hypoxemia in severe alcohol poisoning are emphasized.