The American journal of emergency medicine
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Case Reports
The curious case of a cardiac tamponade in the hypertensive patient presenting as abdominal fullness.
Cardiac tamponade is a medical emergency consisting of an accumulation of fluid in the pericardial space which is rapidly progressing and fatal. Because cardiac tamponade is ultimately a clinical diagnosis, mindful consideration for atypical presentations is essential for the reduction of mortality in the acute setting. Our patient was a 77year-old female admitted after presenting with general malaise, weakness, somnolence, altered mental status and urinary incontinence found to have CML (chronic myeloid leukemia) on confirmatory bone marrow biopsy after suspicions arose from a leukocytosis of 34,000 cells per mcL with 85% neutrophils and elevated blasts (8%). ⋯ Repeat echocardiography exhibited right atrial diastolic collapse, inferior vena cava dilatation (IVC) without inspiratory collapse >50% and the large pericardial effusion consistent with tamponade. The blood pressure remained hypertensive until she suddenly went into cardiac arrest after being intubated for a pericardial window and expired. Our case highlights the need to keep cardiac tamponade as a differential in the hypertensive individual with abdominal complaints as atypical presentations can obscure diagnosis, delay treatment and increase mortality.
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Case Reports
Profound hypotension and bradycardia in the setting of synthetic cannabinoid intoxication - A case series.
Cannabinoids are the most commonly used illegal substances in the world [1]. Synthetic Cannabinoids (SCB) are also known as "Spice", "K2", "Spike", "herbal incense", "Cloud 9", "Mojo" and many others are becoming a large public health concern due to their increasing use, unpredictable toxicity, and abuse potential [2]. The most common reported toxicities with SCB use based on studies using Texas Poison control record are tachycardia, agitation and irritability, drowsiness, hallucinations, delusions, hypertension, nausea, confusion, dizziness, vertigo, chest pain, acute kidney injury, seizures, heart attacks and both ischemic and hemorrhagic strokes [3]. ⋯ Although these patients were drowsy and sleepy at presentation, tactile stimuli would arouse these patients to awaken and participate in an interview. The patients described in this case series, appeared to be on the brink of cardiovascular collapse. The vital signs however normalized with intravenous fluid (IVF) hydration only, over the course of 6 to 7h, allowing a safe discharge from the ED.
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Hyperthermia is a potentially life threatening scenario that may occur in patients due to accompanying morbidities, exertion, or exposure to dry and arid environmental conditions. In particular, heat stroke may result from environmental exposure combined with a lack of thermoregulation. Key clinical findings in the diagnosis of heatstroke are (1) a history of heat stress or exposure, (2) a rectal temperature greater than 40 °C, and (3) central nervous system dysfunction (altered mental state, disorientation, stupor, seizures, or coma) (Prendergast and Erickson, 2014 [1]). ⋯ Invasive approaches may include gastric lavage or peritoneal lavage (Schraga and Kates [4]). The efficacy of these methods vary and select treatment approaches may be unsuitable for specific individuals (Schraga and Kates [4]). In this work, the effectiveness of radiation cooling of individuals as a stand-alone treatment and comparisons with existing noninvasive techniques are presented.
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Abdominal pain is common in children, but expeditious diagnosis of life- or organ-threatening diseases can be challenging. An evidence-based definition of tachycardia in children was established recently, but its diagnostic utility has not yet been studied. ⋯ Tachycardia significantly increased the likelihood of life- or organ-threatening diseases. Tachycardia in children with abdominal pain should alert emergency physicians to the possibility of serious illness.