The American journal of emergency medicine
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Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. ⋯ Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.
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Oncologic imaging in the emergency department (ED) is frequently encountered, including non-acute scans known as "metastatic workups" or "staging" (referred to as "cancer staging computed tomography (CT) exams"). This study examines the impact of oncologic staging CT exams on ED imaging turnaround time (TAT), defined as the time from the end of the CT exam to a final signed radiologist report, as well as order to scan completion time. ⋯ Oncology patients receiving non-acute metastatic workup scans in the ED have a significantly longer TAT compared to non-oncologic ED CT exams as well as longer order to scan completion times.
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As point of care ultrasound (POCUS) has become more integrated into emergency and critical care medicine, there has been increased interest in utilizing ultrasound to assess volume status. However, recent studies of carotid POCUS on volume status and fluid responsiveness fail to recognize the effect insonation angle has on their results. To address this, we studied the effect of insonation angle on peak systolic velocity (PSV) change associated with respiratory variation (RV) and passive leg raise (PLR). ⋯ Variation in PSV is heavily dependent on insonation angle. There was only slight to fair agreement in ∆PSV among the various insonation angles. Further investigation of the optimal insonation angle to assess ∆PSV should be undertaken.
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The purpose of this study was to evaluate the safety and efficacy of a single parenteral dose of phenobarbital in addition to symptom-triggered lorazepam for the acute management of alcohol withdrawal syndrome (AWS). ⋯ More patients were discharged within three days if they received a single parenteral dose of phenobarbital on hospital day one, in addition to symptom-triggered lorazepam for the acute management of AWS. Emergency Medicine physicians should consider ordering one parenteral phenobarbital dose on hospital day one to patients presenting with AWS.
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Studies have shown the value of CT brain imaging in adults with first-time seizures, but there are no recommendations regarding emergent brain CTs in persons with an established seizure disorders. Our study aimed to derive a clinical decision instrument (CDI) to determine which patients with status epilepticus (SE) require emergent brain imaging. ⋯ By using four criteria to identify high risk patients, we can defer CT scanning in the vast majority of patients with SE and known seizure disorders. This CDI should be prospectively validated before adoption.