J Emerg Med
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Case Reports
A "Shark Encounter": Delayed Primary Closure and Prophylactic Antibiotic Treatment of a Great White Shark Bite.
Shark bites are rare but sensational injuries that are covered in the lay press but are not well described in the medical literature. ⋯ We present the case of a 50-year-old man who sustained two deep puncture wounds to his thigh from a great white shark in the waters surrounding Isla de Guadalupe off the coast of Baja California, Mexico, during a caged SCUBA dive. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss our strategy of closing the wounds in a delayed primary fashion 24 hours after injury, our antibiotic choices, and the patient's course and review marine pathogens and appropriate antibiotic coverage.
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Review Meta Analysis
Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis.
Delayed intracranial hemorrhage is a potential complication of head trauma in anticoagulated patients. ⋯ The present study is the first published meta-analysis estimating the risk of delayed intracranial hemorrhage 24 h after head trauma in patients anticoagulated with vitamin K antagonist and normal initial CT scan. In most situations, a repeat CT scan in the emergency department 24 h later is not necessary if the first CT scan is normal. Special care may be required for patients with serious mechanism of injury, patients showing signs of neurologic deterioration, and patients presenting with excessive anticoagulation or receiving antiplatelet co-medication.
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Randomized Controlled Trial
A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits.
Increasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. ⋯ This RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.
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Acute porphyria is historically known as "the little imitator" in reference to its reputation as a notoriously difficult diagnosis. Variegate porphyria is one of the four acute porphyrias, and can present with both blistering cutaneous lesions and acute neurovisceral attacks involving abdominal pain, neuropsychiatric features, neuropathy, hyponatremia, and a vast array of other nonspecific clinical features. ⋯ A 40-year-old man presented to the Emergency Department (ED) as a major trauma call, having been found in an "acutely confused state" surrounded by broken glass. Primary survey revealed: hypertension, tachycardia, abdominal pain, severe agitation, and confusion with an encephalopathy consistent with acute delirium, a Glasgow Coma Scale score of 13, and head-to-toe "burn-like" abrasions. Computed tomography was unremarkable, and blood tests demonstrated hyponatremia, acute kidney injury, and a neutrophilic leukocytosis. The next of kin eventually revealed a past medical history of variegate porphyria. The patient was experiencing an acute attack and received supportive management prior to transfer to intensive care, subsequently making a full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the importance of recognizing acute medical conditions in patients thought to be suffering from major trauma. Acute porphyria should be considered in any patient with abdominal pain in combination with neuropsychiatric features, motor neuropathy, or hyponatremia. Patients often present to the ED without any medical history, and accurate diagnosis can be essential in the acute setting to minimize morbidity and mortality. The label of the major trauma call must be taken with great caution, and a broad differential diagnosis must be maintained throughout a diligent and thorough primary survey.