J Emerg Med
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Dynamic ultrasound guidance reduces complications associated with central venous catheter placement. However, successful central venous cannulation often remains challenging, particularly in hypotensive patients. The new wire-in-needle (WIN) technique can further increase periprocedural safety. Here, a needle is "preloaded" with a guidewire that is then advanced toward the tip of needle. The vein is then cannulated using long-axis ultrasound guidance. ⋯ This study demonstrates that the WIN technique can be learned quickly and easily by clinicians with various levels of training. In this study, using manikins, it was as successful and safe as the traditional short-axis approach.
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Most hypertensive patients have essential (primary) hypertension; only 5% to 10% have a secondary cause. Two clinical characteristics suggestive of secondary hypertension are early onset (< 30 years of age) and severe hypertension (>180/110 mm Hg). When faced with these findings, clinicians should consider a secondary cause of hypertension. ⋯ A 22-year-old woman being evaluated for asthma exacerbation in the emergency department was noted to have severe persistent hypertension. Additional evaluation revealed severe hypokalemia, metabolic alkalosis, and hypernatremia. The patient was admitted to the hospital for blood pressure management, electrolyte replacement, and further evaluation of presumed hyperaldosteronism. Diagnostic imaging revealed a large adrenal mass. Surgical resection was performed, leading to a diagnosis of hyperaldosteronism caused by adrenal carcinoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Secondary hypertension is far less common than essential hypertension; however, considering the large volume of patients seen in emergency departments, it is likely that some will have secondary hypertension. Emergency physicians should be aware of the clinical characteristics that suggest secondary hypertension so that the appropriate diagnostic and treatment pathways can be pursued.
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Lepidopterism refers to the manifestations of contact from any number of moths, butterflies, and caterpillars. Various symptoms have been described, ranging from localized skin irritation to systemic anaphylactic reactions. ⋯ We present a case of airway edema in an 8-month-old child from oral exposure to Woolly Bear Caterpillar (Pyrrharctia Isabella). After prompt emergency department recognition, her symptoms necessitated urgent operating room management by a team of otolaryngologists and close monitoring in a pediatric intensive care unit. A similar presentation in this species has not been described previously in the English literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Leptidopterism is rare, but recognition by the emergency practitioner is necessary for prompt and appropriate treatment. Rapid identification by the emergency physician of oral exposure and careful spine removal can be lifesaving in cases of significant oropharyngeal edema.
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There is controversy regarding whether in-hospital time delay to appendectomy in children with appendicitis affects risk for perforation. ⋯ Increasing in-hospital time delay from ED presentation to OR appendectomy is associated with increased risk for developing appendiceal perforation in children who present with CT-documented uncomplicated appendicitis. Risk is approximately sixfold greater in those who experience delay >9 h vs. those whose delay is ≤9 h. Antibiotic therapy does not reliably prevent progression of the disease. Appendectomy should be considered an urgent procedure to maximize outcomes and prevent complications associated with appendix perforation.