J Emerg Med
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Medical student evaluations are essential for determining clerkship grades. Electronic evaluations have various advantages compared to paper evaluations, such as increased ease of collection, asynchronous reporting, and decreased likelihood of becoming lost. ⋯ EMSEs that were integrated into the emergency department tracking system significantly increased the number of evaluations completed compared to paper evaluations. In addition, the EMSEs captured more "helpful/useful" information about the individual students as evidenced by the longer free text entries per evaluation.
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Approximately 1% of emergency department (ED) visits are due to anaphylaxis. Symptoms can include skin rash, facial and laryngeal edema, dyspnea, vomiting, hypotension, and shock. A transient loss of consciousness can also be a manifestation of anaphylaxis. A variety of electrocardiographic changes due to anaphylaxis have been described for Kounis syndrome, also known as allergic angina. ⋯ Here we describe the case of a male patient presenting at an ED with syncope, anaphylactic shock, and ST-segment elevation on electrocardiogram (ECG). The diagnostic workup led to the diagnosis of ruptured hepatic echinococcal cyst complicated by anaphylactic shock and syncope. ECG alterations were a manifestation of anaphylaxis, as defined by the type I Kounis syndrome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Kounis syndrome represents an underestimated disease. Its prompt diagnosis in an ED has important clinical and therapeutic implications, such as modifications in the anaphylaxis treatment protocol, that is, adrenaline should be avoided because it could worsen vasospasm and myocardial ischemia.
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Despite the common occurrence of hymenopteran stings worldwide, primary neurologic manifestations including stroke are rare. We report a case of a healthy male who developed a right middle cerebral artery (MCA) territory ischemic stroke after getting stung by a wasp. ⋯ A 44-year-old man with hypertension presented to the hospital with sudden-onset left hemiparesis, left facial weakness, and dysarthria after being stung by a wasp. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) scans of the brain revealed a right MCA territory infarct and a lack of flow in the distal right internal carotid artery and MCA. He was treated with intravenous tissue plasminogen activator. A computed tomography angiography scan of the brain performed 24 hours later revealed multiple regions of vasoconstriction in the territory of the bilateral MCA. Evaluations for causes of stroke, including echocardiography and telemetry, were not revealing. Immunologic testing showed significantly elevated levels of serum wasp immunoglobulin E. Therapy with aspirin and atorvastatin was started. At discharge, the patient had a mild left facial droop but normal strength in his left arm and leg. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians encounter large numbers of hymenopteran sting cases each year. These patients typically present with local reactions, such as itching, pain, and erythema. Systemic manifestations, such as anaphylaxis causing severe hypotension and bronchospasm, are less common but deadly. Neurologic complications, such as ischemic stroke, are extremely rare. This manuscript highlights the pathophysiology and management of stroke after a hymenopteran sting. There are no guidelines for the management of stroke after a hymenopteran sting, and therefore we intend to provide some guidance to physicians for treating stroke after a hymenopteran sting.
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Alcoholic ketoacidosis (AKA) is a complex syndrome that results from disrupted metabolism in the setting of excessive alcohol use and poor oral intake. Dehydration, glycogen depletion, high redox state, and release of stress hormones are the primary factors producing the characteristic anion gap metabolic acidosis with an elevated β-hydroxybutyrate (β-OH) and lactate. ⋯ We present the case of a 47-year-old man who presented to the emergency department with metabolic acidosis and profoundly elevated lactate levels who had AKA. He recovered completely with intravenous fluids and parenteral glucose administration. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should always consider the immediately life-threatening causes of a severe anion gap metabolic acidosis and treat aggressively based on the situation. This case highlights the fact that AKA can present with an impressively elevated lactate levels. Emergency physicians should keep AKA in the differential diagnosis of patients who present with a similar clinical picture.
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It has been speculated that freestanding emergency departments (FEDs) draw more affluent, better-insured patients away from urban hospital EDs. It is believed that this leaves urban hospital-based EDs less financially secure. ⋯ There were less privately insured patients and more self-pay, Medicaid, and Medicare patients at the main ED compared to the FEDs. Privately insured patients decreased at both the FEDs and main ED during the study. Insurance distribution was significantly different between the main ED, and three FEDs, and between individual FEDs.