The American journal of emergency medicine
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Urinary tract infections (UTIs) are one of the most common reasons women seek treatment in the emergency department (ED). The biomarker procalcitonin (PCT) has gained popularity over the last decade to improve the diagnosis of bacterial infections and reduce unnecessary exposure to antibiotics. PCT has been extensively studied in patients with pneumonia and sepsis and may have additional role in UTI. ⋯ A PCT threshold <0.25ng/ml was a strong predictor of the absence of UTI. The high negative predictive value of PCT may be useful as an adjunct to urinalysis results to rule out UTI and facilitate noninitiation or earlier discontinuation of empiric antibiotics.
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Volume resuscitation is of utmost importance in the treatment of shock. It is imperative that this resuscitation be guided using a reliable method of ascertaining volume status to avoid the ill-effects of hypovolemia while also avoiding those of over-resuscitation. There are numerous tools and methods available in this era to aid the bedside physician in guiding volume resuscitation, many of which will be described in this review of literature. ⋯ Dynamic measurements are favored over static measurements, however the conditions to be met for most dynamic measurements to be valid leave these methods to be used reliably in a very discrete critically-ill population. This issue is overcome by utilizing maneuvers that have been developed to assess fluid responsiveness that liberalize the conditions required for most dynamic measurements, such as passive leg raising, end expiratory occlusion, and mini-fluid boluses. This review of literature highlights the differences between static and dynamic measurements of fluid responsiveness, and proposes a guide to choosing the most reliable methods of ascertaining volume responsiveness individualized to each patient.
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Randomized Controlled Trial
Simulated internal jugular vein cannulation using a needle-guiding device.
Using a two-dimensional ultrasound-guided approach does not guarantee success during the first attempt at internal jugular vein cannulation. Our randomized, parallel simulation study examined whether a new disposable device could improve the success rate of the first attempt at ultrasound-guided internal jugular vein cannulation of a simulated internal jugular vein. ⋯ The new disposable device was effective for successful first attempts at needle insertion during ultrasound-guided internal jugular vein cannulation. Future clinical trials are needed to assess the effectiveness of this device.
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Review
Ultrasound for identifying the cricothyroid membrane prior to the anticipated difficult airway.
Prior to the anticipated difficult airway, the emergency physician commonly palpates the neck to identify the presumed location of the cricothyroid membrane (CTM). In the event of a "cannot-intubate, cannot‑oxygenate" airway, precise CTM localization is vital to the success of a cricothyrotomy and hence, the patient's survival. ⋯ Emergency physicians may apply this US technique for CTM localization in preparation for an anticipated difficult airway. However, since this technique takes longer than landmark palpation, using US is not recommended once already in the midst of a failed airway situation.
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We describe the hospital course of a 42-year-old patient who presented to the Emergency Department following an ingestion of an unknown quantity of chlorfenapyr, an organochlorine pesticide that acts as a mitochondrial uncoupler (MU). There is limited data on chlorfenapyr toxicity in humans, but reports indicate a 100% mortality rate after a 7-10 day quiescent period.3-6 Our patient was admitted for a 5-day asymptomatic observation period before becoming critically ill. ⋯ The patient expired from complications due to uncontrollable hyperthermia on hospital day 6. This case represents the first reported fatality due to chlorfenapyr in North America, and illustrates: 1) its potency as a human toxin, 2) the futility of extracorporeal decontamination once late toxicity has set in; 3) the potential need for early and aggressive decontamination in the ED; and 4) the need for a better understanding of this unique poison.