The American journal of emergency medicine
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Ambulance diversion is a common and controversial method used by emergency departments (EDs) to reduce stress on individual departments and providers and relieve mismatches in the supply and demand for ED beds. Under this strategy, ambulances bound for one hospital are redirected to another, usually under policies established by regional emergency medical services systems. ⋯ We examine the history and causes of diversion as well as the ethical foundations and practical consequences of it. We contend that (1) from a moral viewpoint, the most important stakeholder is the individual patient because diversion decisions are usually relative rather than absolute; (2) decisions regarding ambulance diversion should be made with careful consideration of individual patient preferences, local and state emergency medical services laws, and institutional surge capacity; and (3) authorities should consider the potential positive effects of a regional or statewide ban on diversion.
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ST elevation (STE) on the electrocardiogram (ECG) may be due to acute myocardial infarction (AMI) or other nonischemic pathologies such as left ventricular aneurysm (LVA). The objective of this study was to validate 2 previously derived ECG rules to distinguish AMI from LVA. The first rule states that if the sum of T-wave amplitudes in leads V1 to V4 divided by the sum of QRS amplitudes in leads V1 to V4 is greater than 0.22, then acute ST-segment elevation MI is predicted. The second rule states that if any 1 lead (V1-V4) has a T-wave amplitude to QRS amplitude ratio greater than or equal to 0.36, then acute ST-segment elevation MI is predicted. ⋯ When patients present to the emergency department with ischemic symptoms and the differential diagnosis for STE on the ECG is AMI vs LVA, these 2 ECG rules may be helpful in differentiating these 2 pathologies. Both rules are highly sensitive and accurate in predicting AMI vs LVA.
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Case Reports
Dual-source computed tomography may define cardiac contusion in patients with blunt chest trauma in ED.
We report a 20-year-old woman with blunt chest trauma because of a motor vehicle injury who has traumatic asphyxia and hypotension. The diagnosis of blunt cardiac injury was put by using dual-energy computed tomography in the emergency department because other laboratory and imaging modalities were useless. After hospitalization in intensive care unit, she was treated with supportive and antiedema therapy. ⋯ Coexistence of traumatic asphyxia with blunt cardiac injury is rare. Several imaging techniques such as transthoracic and transesophageal echocardiography, contrast-enhanced multislice thorax computed tomography or initial electrocardiogram, and troponin I levels are used to detect the myocardial damage, but diagnostic capability is low. Dual-energy computed tomography is a promising new technology with the ability of defining blunt cardiac injuries and may have an indication in the emergency setting in patients with hemodynamic instability to rule in traumatic cardiac complications especially when electrocardiogram and transthoracic echocardiography are useless in the emergency department.
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There are more than 1 million cases of scorpion envenomation worldwide. Severe complications due to myocardial depression can happen in some patients, mainly children. A catecholamine-induced myocarditis probably causes this cardiac dysfunction. ⋯ The CMR showed an apical ballooning in the left ventricle associated with a left ventricle ejection fraction of 29% and a global edema of the midmyocardium and apical myocardiumin the T2-weighted triple inversion recovery images. The CMR was repeated after 7 months and showed complete recovery of the wall motion in the apical region and of the myocardial function (left ventricle ejection fraction, 60%) associated with normalization of the signal in the T2-weighted triple inversion recovery images. These clinical and laboratory findings, mainly the CMR images, are similar to those observed in stress-induced cardiomyopathy (Takotsubo) reinforcing the hypothesis that the catecholamine's excess has a pivotal function in the pathophysiology of the cardiac dysfunction in these 2 conditions.