J Emerg Med
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Review Practice Guideline
Safety of Droperidol Use in the Emergency Department.
Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone used in emergency medicine practice for a variety of uses. QT prolongation is a well-known adverse effect of this class of medications. Of importance to note, QT prolongation is noted with multiple medication classes, and droperidol increases QT interval in a dose-dependent fashion among susceptible individuals. The primary goal of this literature search was to determine the reported safety issues of droperidol in emergency department management of patients. ⋯ Droperidol is an effective and safe medication in the treatment of nausea, headache, and agitation. The literature search did not support mandating an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either intramuscularly or intravenously. Intramuscular doses of up to 10 mg of droperidol seem to be as safe and as effective as other medications used for sedation of agitated patients.
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Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that is classically characterized by fluctuating weakness and fatigability of the ocular, bulbar, limb, or respiratory muscles. Over half of patients with MG will initially experience isolated ocular symptoms in one or both eyes. Most patients report that ocular symptoms are mild or undetectable upon awakening, and worsen throughout the day or with tasks such as driving. We describe an unusual case of MG presenting with an acute onset of persistent unilateral ptosis and ipsilateral facial droop without diurnal variation or other fluctuation in severity. ⋯ A 58-year-old man presented to the Emergency Department with a 3-day history of persistent, unilateral ptosis with facial droop, concerning for stroke. However, magnetic resonance imaging of the head found no evidence of stroke or any other central etiology. Routine laboratory testing was unremarkable. Neurology was consulted and they recommended sending acetylcholine receptor antibody tests. At the patient's subsequent neurology clinic visit, these tests were found to be abnormal. Electromyography was also done at this visit, confirming the diagnosis of MG. The patient subsequently underwent thymectomy and immunosuppressive therapy, with great improvement in his symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: MG may present as unilateral ptosis or facial drooping without the hallmark characteristic of fluctuating muscle weakness. Early diagnosis and subsequent treatment of MG improves long-term prognosis and remission rates. Emergency physicians should consider myasthenia gravis in cases of unilateral ocular symptoms after ruling out emergent central etiologies.
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In part 1 of this two-part review, we discussed which risk factors, historical features, and physical findings increase risk for pulmonary embolism (PE) in symptomatic emergency department (ED) patients. ⋯ Reasonable and prudent emergency clinicians can exclude PE in symptomatic ED patients on clinical grounds alone in many patients, and many more can have PE ruled out by use of the D-dimer.
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Rapid sequence intubation (RSI) involves a rapidly acting sedative plus a neuromuscular blocking agent (NMBA) to facilitate endotracheal intubation. Rocuronium and succinylcholine are NMBAs commonly used in RSI with drastically different durations of action. ⋯ Patients receiving rocuronium in RSI had a significantly longer time to sedation or analgesia when compared to patients receiving succinylcholine. The presence of an EPh significantly decreased the time to administration of sedation or analgesia after RSI.
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National emergency department (ED) bounceback rates within 30 days of previous ED discharge have been found to be as high as 26%. We hypothesize that having a primary care physician (PCP) would prevent bouncebacks to the ED because a patient would have a medical resource for follow-up and continued care. ⋯ Our results suggest that patients who bounce back to the ED might have already contacted their PCP. Although insurance status and the lack thereof predict a higher likelihood to bounce back to the ED, many bouncebacks are insured patients with PCPs able to be seen the same day.