The American journal of emergency medicine
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Acute headache is a common emergency department (ED) chief complaint that usually has a benign course. Rare etiologies such as subarachnoid hemorrhage (SAH) can lead to extensive disability or even death. If suspected, SAH requires an intricate and intensive diagnostic investigation. ⋯ However, 3 days later upon re-presentation to the ED with the same symptoms, an LP was positive for increasing red blood cell count in subsequent tubes. She was transferred to a facility with interventional neurology capabilities where digital subtraction angiography showed a left anterior choroidal saccular aneurysm for which she underwent coiling. Given recent changes in SAH clinical practice guidelines, this case highlights the importance of understanding the current limitations of CT imaging, understanding the risks and benefits of both CT and LP, and always maintaining a high suspicion for especially lethal and disabling conditions such as SAH.
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Procedural sedation for electrical cardioversion is a common practice in the emergency department (ED). Ideal sedative properties for this procedure are a short half-life and minimal hemodynamic effects. There is limited literature examining methohexital for this use. ⋯ Methohexital was found to have a similar efficacy and safety profile when compared to propofol and etomidate when used as procedural sedation for cardioversions in the ED.
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Central nervous system (CNS) infections are often suspected in adult patients with fever-associated seizures. However, it is unclear whether lumbar puncture (LP) is routinely required in patients with fever-associated seizures. This study aimed to examine the prevalence of meningitis and encephalitis in adult patients with fever-associated seizures and to evaluate whether LP is routinely required. ⋯ The prevalence of meningitis or encephalitis is relatively low in adult patients with fever-associated seizures. Lumbar puncture is considered unnecessary to be performed routinely, but its indication should be carefully considered with reference to the clinical course, comorbidities, and blood tests. Further validation studies with larger sample sizes are needed to confirm the findings of this study.
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Case Reports
Severe caffeine poisoning successfully treated with high flow continuous hemodialysis: A case report.
In recent years, severe or lethal cases of caffeine poisoning after large or massive ingestion of caffeinated tablets have increased in Japan. Here we report the case of a 23-year-old male who ingested high-dose caffeine tablets (total: 32.4 g caffeine) in a suicide attempt. He was transferred to our hospital about 2 h after ingesting the tablets and presented with repeated vomiting and tremor in the trunk and extremities. ⋯ This dramatically improved his clinical signs and symptoms, especially during the first 3 h. His serum caffeine concentration was 240.9 μg/mL on admission and 344.0 μg/mL at the initiation of high flow CHD, but rapidly decreased to 153.8 μg/mL 3 h after initiating high flow CHD. Our findings suggest that high flow CHD may be effective in treating cases of severe caffeine poisoning with hemodynamics too unstable for intermittent hemodialysis.
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Peri-intubation cardiac arrest is an uncommon, serious complication following endotracheal intubation in the emergency department. Although several risk factors have been previously identified, this study aimed to comprehensively identify risk factors associated with peri-intubation cardiac arrest. ⋯ Patients with hypotension before intubation have a higher risk of peri-intubation cardiac arrest in the emergency department. Future studies are needed to evaluate the influence of resuscitation before intubation and establish airway management strategies to avoid serious complications.