J Emerg Med
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Review Case Reports
Head and Neck Myiasis, Cutaneous Malignancy, and Infection: A Case Series and Review of the Literature.
There is a paucity of literature on wound myiasis of the head and neck originating in the United States. To our knowledge, only three reports during the past 20 years exist in the literature. Even less common is a case of recurrent myiasis, with only one report published from India during the 1970s. There is often a preconceived notion that larvae are noninvasive and "only eat dead tissue." This mentality must be corrected; invasive larvae exist, there are unique myiasis-related infections, and serious complications can occur. We review the literature and describe recent cases of head and neck myiasis treated at our institution in upstate New York. ⋯ Four cases, all initially presenting to the emergency department, were identified. Each case was superimposed on cutaneous malignancy and all patients presented with leukocytosis and positive blood or wound cultures. In the case of the recurrent myiasis, initial treatment was external beam radiation therapy for the malignancy, which had the added benefit of eradicating the larvae. Treatment for the other cases was limited to antibiotics and supportive care for medical comorbidities. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Serious complications can develop from head and neck myiasis and, in our experience, an underlying malignancy should be suspected. Proper management is critical and should include, at a minimum, empiric antibiotics, tetanus prophylaxis, biopsy of the surrounding tissue, and reporting to the appropriate health agency. Additional management can include bedside debridement, pharmacologic antiparasitics, and treatment of the underlying disorder.
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Observational Study
Hemodynamic Effects of Nitroglycerin Ointment in Emergency Department Patients.
Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. ⋯ Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change after application of nitroglycerin ointment in these patients.
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Anaphylaxis is the quintessential critical illness in emergency medicine. Symptoms are rapid in onset and death can occur within minutes. Approximately 1500 patients die annually in the United States from this deadly disorder. It is imperative, therefore, that emergency care providers be able to diagnose and appropriately treat patients with anaphylaxis. Any delays in recognition or initiation of therapy can result in unnecessary increases in patient morbidity and mortality. ⋯ For patients with anaphylaxis, rapid and appropriate administration of epinephrine is critical for survival. Additional therapy, such as supplemental oxygen, intravenous fluids, antihistamines, and corticosteroids should not delay the administration of epinephrine.
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Endotracheal intubation is a common procedure in the emergency department, and new devices may improve intubation time, success, or view. ⋯ The KVVL was slightly faster than Macintosh DL in two of four studied airway scenarios, and had a higher success rate in the difficult cadaver airway scenario. Further study is required in the clinical setting.
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Case Reports
Retroperitoneal and Cutaneous Necrotizing Fasciitis Secondary to Necrotizing Pancreatitis.
Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10-25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess. ⋯ We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course.