The American journal of emergency medicine
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Physicians need to consider a broad differential diagnosis when evaluating a patient presenting with a suspected stroke. The rates of overdiagnosis of stroke in studies of consecutive patients vary from 19% to 31%. The two most common stroke mimics are hypoglycemia and seizure, but several etiologies have been reported. We reported the case of a 41-year-old patient presenting to the emergency department with aphasia and right-side hemiparesis, initially suspected to have stroke and finally diagnosed of varicella-zoster encephalitis.
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The evidence for prognostication using lactate is often based on arterial lactate (AL). Arterial sampling is painful and difficult, and carries risks. Studies comparing peripheral venous lactate (PVL) with AL showed little difference but predominantly included patients with normal lactate. The objective of this study was to measure agreement between PVL and AL in patients with elevated venous lactate. ⋯ We report greater bias between VL and AL with broader LOA than previously documented. This may partly be due to the fact that we studied only patients with abnormal venous values, for whom close agreement would confer greatest clinical significance. The agreement between abnormal PVL and AL is poor and the high rate of misclassification may suggest that PVL is not a good substitute for AL if the venous lactate is abnormal.
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Torsade de pointes is a form of polymorphic ventricular tachycardia that differs from other forms of ventricular tachycardia in its morphology, precipitating factors, and therapeutic approach. Its recognition is of utmost importance, as the standard anti-arrythmic drugs not only might be ineffective in its termination but also may aggravate it. Herein, we report a case of antipsychotic-induced torsade de pointes and describe the use of magnesium sulfate, isoproterenol, and phenytoin and their proposed mechanism of action.
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Checklists have successfully been used in intensive care units (ICUs) to improve metrics of critical care. Proper peri-intubation care including use of appropriate induction agents and postintubation sedation is crucial when performing endotracheal intubation (ETI) on critically ill patients, especially in the emergency department (ED). We sought to evaluate the impact of checklists on peri-intubation care in ED trauma patients. ⋯ Peri-intubation checklists result in higher rates of RSI in ED trauma patients but do not alter other measured metrics of peri-intubation care.
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Clinical Trial
Towards a less invasive approach to the early goal-directed treatment of septic shock in the ED.
Early goal-directed therapy (EGDT) in septic shock defined by Rivers et al was proven to reduce mortality and validated by observational studies. However, criticism is centered in particular on the early requirement of a central venous catheter (CVC) and on central venous pressure (CVP) as an indicator of volume responsiveness. The present study is a pivotal study to investigate the reliability of a less invasive approach, which uses inferior vena cava (IVC) and lung ultrasounds (US) to guide the infusion of fluids and lactate clearance to monitor tissue perfusion. ⋯ Our approach to resuscitation in septic shock appears feasible in the emergency department and needs further study with a randomized controlled trial.