J Emerg Med
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T-wave morphology in the setting of left bundle branch block (LBBB) has been proposed as an indicator of myocardial ischemia. ⋯ We found no clinically useful relationship between T-wave concordance and myocardial infarction in our patient population. Future investigation of LBBB T-wave morphology should focus on alternative populations and findings.
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Epistaxis is a common problem that occurs in up to 60% of the general population, and is a common emergency department (ED) complaint. The use of lidocaine for analgesia is common when cauterization is required for bleeds that are refractory to manual compression. Although the use of lidocaine is generally thought of as a benign intervention, it is not completely without risk. ⋯ We present the case of a 19-year-old man who presented to the ED with persistent anterior epistaxis. He developed severe lidocaine toxicity resulting from topical anesthesia applied prior to intranasal cautery for the epistaxis. This toxicity, which manifested as seizures, bradycardia, hypotension, nausea, and emesis, was rapidly recognized and appropriately treated, with a good clinical outcome for the patient. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the potential complications of the intranasal use of topical lidocaine, something that is generally considered a benign intervention. We also discuss the pathophysiology and management of lidocaine toxicity.
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Case Reports
Left Atrial Compression Caused by an Intrapericardial Hematoma after Coronary Artery Bypass Graft Surgery.
Left atrial compression (LAC) is an uncommon condition that causes left ventricular inflow obstruction. The clinical and pathologic features are similar to those of mitral stenosis. Impaired left ventricular filling may cause hypotension, syncope, or shock. The increased left atrial pressure causes retrograde increase of the pressure throughout the pulmonary circulation with subsequent signs of congestion. ⋯ An 84-year-old man presented with LAC caused by a focal tamponade related to a pericardial hematoma as a complication of coronary artery bypass graft (CABG) surgery. The formation of the hematoma occurred 3 weeks postsurgery. The echocardiographic study before discharge at day 12 after CABG surgery showed neither a focal hematoma nor a tamponade. The diagnosis was made 6 days later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Intrapericardial tamponade caused by bleeding is a known complication of CABG surgery in the early postoperative stage. However, emergency physicians should be aware that a postoperative hematoma may also present as a focal tamponade because of postoperative adhesion by scar formation. The literature of LAC is limited. The most reported causes of LAC are compression caused by structures of the gastrointestinal tract, followed by thoracic aortic pathology. A Medline search for the terms "left atrial compression and hematoma" and "left atrial compression and intrapericardial hematoma" found only 31 and 4 hits, respectively. We also briefly discuss the import role of bedside echocardiography in the diagnostic process of LAC in the emergency medicine department.
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Carbon monoxide-related symptoms caused by water pipe smoking may be a frequent occurrence. This might often be overlooked, because patients will not always identify the smoke exposure as the cause of their presenting complaints and may well withhold this information. ⋯ A series of three patients who were 15 to 28 years of age presented to the emergency department with nonspecific symptoms and were found to have carbon monoxide poisoning from water pipe smoking. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case series might improve recognition of this phenomenon. Carbon monoxide poisoning can cause serious problems, yet it could be easily diagnosed and treated. Identifying this condition can expedite treatment and prevent unnecessary diagnostic tests in an attempt to explain its symptoms.