J Emerg Med
-
Case Reports
Ultrasound-guided Greater Auricular Nerve Block for Emergency Department Ear Laceration and Ear Abscess Drainage.
Adequate emergency department (ED) anesthesia for painful ear conditions, such as ear lacerations or ear abscesses, can be challenging. Much of the sensory innervation of the ear is supplied from the anterior and posterior branches of the greater auricular nerve (GAN). The GAN is a branch of the superficial cervical plexus, which arises from the C2/C3 spinal roots. The GAN innervation includes most of the helix, antihelix, the lobule, and the skin over the mastoid process and parotid gland. Anesthesia of the GAN is commonly performed in emergency medicine as part of a landmark-based ear "ring" block. Recently, a selective ultrasound-guided GAN block has been described. ⋯ We report the first cases of ultrasound-guided greater auricular nerve block (UGANB) successfully performed in the ED as the sole procedural anesthesia for both an ear laceration and abscess drainage. In addition, we review the relevant anatomy and technical details of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our cases suggest that UGANB is a potentially effective nerve block for ED management of acute ear pain related to procedures involving the tail of the helix and the lobule, such as ear lacerations or ear abscess incision and drainage. Advantages include real-time visualization of the GAN that may increase block success and the decreased volume of local anesthetic required for a block.
-
The landscape of the emergency medicine workforce has changed dramatically over the last few decades. The growth in emergency medicine residency programs has significantly increased the number of emergency medicine specialists now staffing emergency departments (EDs) throughout the country. Despite this increase in available providers, rising patient volumes, an aging population, ED overcrowding and inefficiency, increased regulation, and other factors have resulted in the continued need for additional emergency physicians. ⋯ There remains a shortage of board-certified emergency physicians, but it is decreasing every year. The use of physicians from other specialties to staff EDs has long been based on the theory that there is a long-standing shortage of available American Board of Emergency Medicine/American Osteopathic Board of Emergency Medicine physicians, both now and in the future. Our investigation shows that this is not supported by current data. Although there will always be regional and rural physician shortages, these are mirrored by all other specialties and are even more pressing in primary care.
-
Pregnancy outcomes after emergency contraceptive use has been debated over time, but review of the literature includes mechanisms by which these medications may increase the chance of an ectopic pregnancy. Such cases are infrequently reported, and many emergency providers may not readily consider this possibility when treating patients. ⋯ This is a case presentation of ectopic pregnancy in a patient who had recently used Plan B (levonorgestrel) emergency contraceptive. She presented with abdominal pain and vaginal spotting, and was evaluated by serum testing and pelvic ultrasound. She was discovered to have a right adnexal pregnancy. She was treated initially with methotrexate, though she ultimately required surgery for definitive treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report aims to bring a unique clinical case to the attention of emergency providers. The goal is to review research on the topic of levonorgestrel use and the incidence of ectopic pregnancies. The mechanism of action of this emergency contraceptive is addressed, and though no definite causal relationship is known between levonorgestrel and ectopic pregnancies, there is a pharmacologic explanation for how this event may occur after use of this medication. Ultimately, the emergency provider will be reminded of the importance of educating the patient on the possible outcomes after its use, including failure of an emergency contraceptive and the potential of ectopic pregnancy.
-
Case Reports
Hypercortisolism Manifesting as Severe Weight Loss, Hypokalemia, and Hyperglycemia in the Emergency Department.
The concurrence of ectopic adrenocorticotropic hormone (ACTH) syndrome (ectopic Cushing syndrome) and cancer is uncommon in the emergency department (ED) setting, but a constellation of nonspecific signs and symptoms can suggest the presence of Cushing syndrome. ⋯ A 65-year-old woman with diabetes visited the ED complaining of severe weight loss, generalized weakness, and hypokalemia. She was treated for hypokalemia and thrush. She was found to have a lung mass with a large pleural effusion. Upon discovery of the suspected malignancy, the patient was referred to the ED of a comprehensive cancer center, where she was diagnosed with ectopic Cushing syndrome and admitted to the hospital for further evaluation and treatment. WHY SHOULD THE EMERGENCY PHYSICIAN BE AWARE OF THIS?: The emergency physician should be able to recognize Cushing syndrome in cancer patients so that the paraneoplastic syndrome can be managed to avoid complications during cancer treatment.