J Emerg Med
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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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Comparative Study
Difference Between Bladder and Esophageal Temperatures in Mild Induced Hypothermia.
Mild induced hypothermia is an established treatment strategy for comatose survivors of cardiac arrest. The goal of the induction phase of mild induced hypothermia is to cool the patient's core body temperature to 32°-34°C. ⋯ Our results indicate that esophageal temperature measurements show a faster response rate compared to temperature measured in the bladder when cold saline infusion is used to induce mild hypothermia.
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The incidence of cardiac pacemaker implantation has risen markedly in the past three decades, making awareness of possible postprocedural complications critical to the emergency physician. This case is the first documented instance of internal jugular (IJ) deep vein thrombosis (DVT) from an uncomplicated pacemaker generator replacement. ⋯ A patient presented to an Emergency Department with a 2-day history of mild left temporal headache migrating to his left neck. The patient did not volunteer this information, but review of systems revealed a temporary transvenous pacemaker inserted through the right IJ vein 1 week previously during a routine exchange of a left-sided cardiac pacemaker generator. Manipulation of the existing pacemaker wires entering the left subclavian vein was minimal. Computed tomographic angiography of the neck demonstrated near-complete thrombotic occlusion of the entire length of his left IJ vein. This required hospital admission for observation and treatment with anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: DVT, with thrombotic extension into adjacent vessels anywhere along the course of pacemaker wires, should be considered by the emergency provider in the evaluation of head, neck, or upper extremity symptoms after recent or remote implantation or manipulation of a transvenous cardiac pacemaker, including generator replacement. Failure to identify and treat appropriately could result in significant morbidity and mortality from airway edema, septic thrombophlebitis, superior vena cava syndrome, superior sagittal sinus thrombosis, or pulmonary embolism.
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The American Heart Association recommends a "meticulous history" when evaluating patients with an initial episode of syncope. However, little is known about which historical features are most helpful in identifying children with undiagnosed cardiac syncope. ⋯ Our study, which represents the largest published series of pediatric syncope presenting to the ED, confirms that newly diagnosed cardiac causes of syncope are rare. Using a few specific historical features on initial interview can help guide further work-up more precisely.