The American journal of emergency medicine
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Case Reports
T-wave inversions in inferior ST-elevation myocardial infarction - A case of "inferior Wellens sign".
Although T-wave inversions are nonspecific, in the appropriate clinical setting, the pattern of negative biphasic T-waves or T-wave inversion in V2-V3 can indicate critical stenosis of the left anterior descending coronary artery (i.e. "anterior Wellens sign"). Recently tall T-waves in V2-V3 have been reported in association with posterior reperfusion (i.e."posterior Wellens sign"). Less commonly, negative biphasic T-waves or T-wave inversions in the inferior leads have been reported in association with critical stenosis of the right coronary artery (RCA) or left circumflex artery (LCx). We present a case where T wave inversions (i.e. "inferior Wellens sign") and a tall T-wave in V2-V3 (i.e. "posterior Wellens sign") preceded the development of an inferior-posterior ST-elevation myocardial infarction (STEMI). ⋯ A 37-year-old man presented to the Emergency Department for one day of chest pain. On arrival, his pain had resolved, and his 1st ECG showed inverted/biphasic T-waves in lead III and aVF and a tall T wave in V2-V3. Three- and one-half hours after arrival, his chest pain returned and his ECG showed an inferior-posterior STEMI. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: New, focal T-wave inversions in an anatomic distribution may be an early warning sign of impending myocardial infarction. Careful attention to the T-waves during asymptomatic periods may assist in identifying patients that may have critical stenosis of an underlying coronary artery. In this case, T-wave inversions in the inferior leads, along with a tall T-wave in V2-V3, were seen prior to the development of an inferior-posterior STEMI.
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Sympathetic crashing acute pulmonary edema (SCAPE) describes the most severe presentation of acute heart failure (AHF). Immediate intervention is required to prevent hemodynamic decompensation and endotracheal intubation. Although high-dose nitroglycerin (>100 μg/min) has been described for this clinical scenario in limited case reports, the concern for adverse effects such as hypotension and syncope limit providers comfortability in initiating nitroglycerin at these doses. Described here is a case series of four patients who safely and effectively received high-dose nitroglycerin infusions for the management of SCAPE.
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Transaminase elevations can occur from liver injury or in the setting of rhabdomyolysis. The goal of this study is to evaluate indices that could differentiate acetaminophen toxicity from muscle injury in the setting of transaminase elevations. ⋯ Elevated transaminases due to liver injury from acetaminophen ingestion had a different pattern than elevated transaminases due to rhabdomyolysis. Lower AST:ALT ratios were found in acetaminophen cases, however, the specificity using a ratio threshold of ≤1 would be 83%.
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Current guidelines recommend systematic care for patients who experience out-of-hospital cardiac arrest (OHCA) and the development of cardiac arrest centers (CACs). However, data regarding prolonged transport time of these often hemodynamically unstable patients are limited. ⋯ Individuals who experienced OHCA and taken to a CAC incurred significantly prolonged transport times; however, hemodynamic parameters and/or outcomes were not affected. These findings shows the safety of bypassing local hospitals for a CAC.
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We hypothesized that resident characteristics impact patterns of patient self-assignment in the emergency department (ED). Our goal was to determine if male residents would be less likely than their female colleagues to see patients with sensitive (e.g. breast-related or gynecologic) chief complaints (CCs). We also investigated whether resident specialty was associated with preferentially choosing patients with more familiar chief complaints. ⋯ In a single facility, resident characteristics were associated with preferential patient self-assignment. Further work is necessary to determine the underlying reasons for patient avoidance, and to create work environments in which preferentially choosing patients is discouraged.