J Emerg Med
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Emergency medicine (EM) is a recently recognized specialty in India, still in its infancy. Local training programs are developing, but remain very limited. Private, for-profit hospitals are an important provider of graduate medical education (GME) in India, and are partnering with United States (US) universities in EM to expand training opportunities. ⋯ This unique partnership is playing a major early role in EM GME in India. Future steps include official program recognition, expanded numbers of training sites, and a gradual transition of training and education to local faculty. Similar partnership programs may be effective in other settings outside of India.
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Aluminum phosphide (AlP) poisoning carries a high rate of mortality despite intensive care management, primarily because of refractory myocardial depression, resistant hypotension, and severe metabolic acidosis as well as acute respiratory distress syndrome. Extracorporeal membrane oxygenation (ECMO) is a modified "heart-lung" machine to provide temporary cardiorespiratory support. We studied the novel use of ECMO in the management of a subset of patients with AlP poisoning. ⋯ In this case series, seven patients with AlP poisoning suffering from severe metabolic acidosis and refractory cardiogenic shock with a reduced left ventricular ejection fraction (<35%) received ECMO treatment. The acidosis and hemodynamic status improved within 6-12 h and 12-24 h, respectively, in five patients. Two patients did not survive because of a long delay in presentation after ingestion. The majority of the patients developed dysrhythmias, ECMO cannulation site bleeding, and thrombocytopenia. Two patients required surgical exploration of the femoral artery. At 9 months of follow-up, all five surviving patients were doing well, with the near normalization of ventricular function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We have found that timely intervention with ECMO in patients with AlP poisoning-induced severe metabolic acidosis and refractory cardiogenic shock may lead to a significant improvement in overall survival. Therefore, ECMO might be considered as a bridge therapy for patients with intractable cardiorespiratory failure caused by AlP poisoning who are not responding to conventional treatment. ECMO, however, also is associated with significant complication rates, which must be incorporated into the risk-benefit analysis while considering treatment options.
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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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Arterial gas embolism (AGE) is a major cause of morbidity and mortality in self-contained underwater breathing apparatus (SCUBA) diving and certain medical procedures. There are currently no well-defined criteria to diagnose AGE. Emergency physicians often find themselves facing a decision whether or not a patient with dive-related symptoms has an AGE and needs to be transferred to a hyperbaric facility. ⋯ The SANDHOG criteria appear to be reliable in diagnosing AGE. AGE is unlikely with SANDHOG scores <2, whereas SANDHOG scores ≥2 resulted in high sensitivity and specificity for AGE. Emergency physicians may find this tool useful in evaluating patients for suspected AGE, and it may assist in determining whether to transfer the patient to a hyperbaric facility. Future studies should be performed to further examine and validate the accuracy and inter-rater reliability of this tool.
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Since 2010, several novel oral anticoagulants (NOACs) have been approved by the United States Food and Drug Administration for the use in the prevention of cerebrovascular accidents (CVAs) in nonvalvular atrial fibrillation. ⋯ There has been a steady increase of ED patients who are taking an NOAC. There is a nearly double admission rate for an anticoagulated patient regardless of reason for ED visit. There appears to be no difference between rates of bleeding between warfarin and NOACs, although patients taking NOACs are admitted less often for intracranial hemorrhage.