J Emerg Med
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Endotracheal intubation remains a cornerstone of early resuscitation of the poisoned patient, but little is known about which substances are associated with intubation. ⋯ The most common substances involved in single- and multiple-substance exposures managed with intubation varied by age group. Most patients were managed with supportive care. Knowledge of substances commonly involved in exposures managed with intubation may inform triage and resource planning in the emergency department resuscitation of critically ill poisoned patients.
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Fractures are a frequent reason for emergency department visits and evaluation for abusive head trauma is an associated concern in infants. Recent guidelines have suggested that retinal examination may not be necessary in the absence of intracranial injury, but there is a lack of empirical evidence in infants < 1 year of age. ⋯ In infants < 1 year of age presenting with isolated long bone fractures, a dilated eye examination to evaluate for retinal hemorrhages is not likely to yield additional information. Our results support recent studies that a subset of children and infants may not require dilated eye examinations in the evaluation of possible abuse.
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Comparative Study
Comparison of Weight-Based Dose vs. Standard Dose Diltiazem in Patients with Atrial Fibrillation Presenting to the Emergency Department.
Despite evidence-based recommended weight-based (WB) dosing of diltiazem for the initial treatment of atrial fibrillation (AF) with rapid ventricular response (RVR), many providers utilize lower initial doses of diltiazem. ⋯ In patients presenting to the ED, we found that standard dose diltiazem was noninferior to WB dosing in the initial treatment of AF with RVR.
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Case Reports
Acute Aortic Dissection Presenting as Bilateral Lower Extremity Paralysis: A Case Report.
First described by Morgagni in 1761, aortic dissection (AD) is an acute life-threatening and time-sensitive disease process with an increasing mortality approaching 1% for every 1-hour delay in diagnosis within the first 48 hours. Despite continued surgical advancement, overall in-hospital mortality remains significant (27.4%). ⋯ A 56-year-old woman presented to an outlying emergency department with a complaint of isolated lumbar pain associated with right lower extremity paresthesia and paralysis that progressed to the left. Her medical history and a review of symptoms were significant for chronic obstructive pulmonary disease and tobacco abuse. The initial evaluation in the emergency department included laboratory values and a computed tomography scan of the lumbar spine that revealed minimal disease. After transfer to our tertiary care center for an emergent magnetic resonance imaging scan of the lumbar spine, her vital signs were as follows: blood pressure, 176/84 mm Hg; heart rate, 76 beats/min; respiratory rate, 24 breaths/min; afebrile; and oxygen saturation 98% on room air. A repeat examination revealed cold extremities with mottling, bilateral symmetric lower extremity flaccid paralysis, and a loss of pulses and reflexes. She was insensate below the T10 dermatome. Her upper extremities and cranial nerves were normal. She underwent computed tomography angiography, revealing an extensive Stanford type A AD with interim thrombus formation. After successful endograft stenting, she died 24 hours later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Comprising <2% of all ADs, the pathophysiology of paraplegia as the initial presentation of AD is caused by compression of the anterior spinal artery, resulting in ischemia of the spinal cord. Acute AD is a life-threatening medical emergency that requires a high clinical level of suspicion because of its often variable presentation and high incidence of mortality.
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As decontamination trends have evolved, gastric lavage (GL) has become a rare procedure. The current information regarding use, outcomes, and complications of GL could help refine indications for this invasive procedure. ⋯ Toxic agents for which GL was performed reflected a broad spectrum of potential hazards, some of which are not life-threatening or have effective treatments. Continuing emergency physician and poison center staff education is required to assist in patient selection.