J Emerg Med
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Case Reports
Embolic Central Retinal Artery Occlusion Detected with Point-of-care Ultrasonography in the Emergency Department.
Ocular emergencies account for 2-3% of all emergency department (ED) visits. Sonographic evaluation of the eye offers a very useful diagnostic tool in the ED. In the ED setting, ocular ultrasound could identify a retinal detachment, or a massive vitreous hemorrhage, and the training for emergency medicine practitioners is quite easy. ⋯ An 84-year-old woman presented to our ED with a painless acute vision loss in her right eye. Immediate bedside emergency ocular ultrasound was performed, and it showed a retrobulbar hyperechoic material, suggestive of an embolus within the central retinal artery. Fluorescein angiography showed limited and sluggish filling of the retinal arteries after injection of fluorescein, and optical coherence tomography demonstrated a decrease in the reflectivity and thickness of the inner retinal layers. The final diagnosis was embolic central retinal artery occlusion (CRAO). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Among the causes of acute loss of vision, CRAO is associated with systemic vascular disease. The importance of visible retinal emboli has been well documented due to its association with increase in mortality. A rapid evaluation of the central retinal artery could be a simple tool to identify an embolus, and this could lead to a rapid treatment. The evaluation of central retinal artery is a less defined setting in emergency physician bedside ultrasound, but the identification of CRAO could lead to a rapid acceleration in diagnosis and treatment of a potentially life-threatening disease.
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Heat stroke is an illness with a high risk of mortality or morbidity, which can occur in the young and fit (exertional heat stroke) as well as the elderly and infirm (nonexertional heat stroke). In the United States, from 2006 to 2010, there were at least 3332 deaths attributed to heat stroke. ⋯ Ice-water immersion has been shown to be highly effective in exertional heat stroke, with a zero fatality rate in large case series of younger, fit patients. In older patients with nonexertional heat stroke, studies have more often promoted evaporative plus convective cooling. Evaporative plus convective cooling may be augmented by crushed ice or ice packs applied diffusely to the body. Chilled intravenous fluids may also supplement primary cooling. Based on current evidence, ice packs applied strategically to the neck, axilla, and groin; cooling blankets; and intravascular or external cooling devices are not recommended as primary cooling methods in heat stroke.
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Spontaneous intracranial hypotension (SIH) is a difficult diagnosis, especially in an emergency department (ED) setting where magnetic resonance imaging (MRI) is usually not available. ⋯ The presence of a tentorial subdural hygroma on brain CT in a patient with orthostatic headache may strongly suggest the diagnosis of intracranial hypotension. This finding can be of high clinical significance in an emergency setting, avoiding additional invasive or expensive procedures.