J Emerg Med
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Case Reports
Enabling Donation after Cardiac Death in the Emergency Department: Overcoming Clinical, Legal, and Ethical Concerns.
In light of the growing gap between candidates for organ donation and the actual number of organs available, we present a unique case of organ donation after cardiac death. We hope to open a discussion regarding organ procurement from eligible donors in the prehospital and emergency department setting. ⋯ We believe that this case shows that donation after cardiac death from the emergency department, while resource-intensive is feasible. We recognize that in order for this to become a more attainable goal, additional resources and systems development is required.
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Focused cardiac ultrasound (FoCUS) is accurate for determining the presence of a pericardial effusion. Using FoCUS to evaluate for pericardial tamponade, however, is more involved. Many experts teach that tamponade is unlikely if the inferior vena cava (IVC) shows respiratory variation and is not distended. ⋯ A 53-year-old woman presented to the emergency department (ED) with severe orthostatic hypotension, exertional dyspnea, and hypoxia. The evaluation did not reveal an acute cardiopulmonary etiology, but FoCUS demonstrated a pericardial effusion, with several signs consistent with tamponade. The IVC, however, was not distended. She was believed to be hypovolemic, but fluid therapy provided minimal benefit. The patient's condition improved only after aspiration of the effusion. The patient's presentation was likely a "low-pressure" pericardial tamponade. Patients with this subset of tamponade often do not have significant venous congestion, but urgent pericardial aspiration is still indicated. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pericardial tamponade may not manifest with IVC plethora on ultrasound. Patients with low-pressure tamponade do not present with the most florid signs of tamponade, but they nonetheless fulfill diagnostic criteria for tamponade. If a non-plethoric IVC is used to rule out tamponade, the clinician risks delaying comprehensive echocardiography or other tests. Furthermore, the potential for deterioration to frank shock could be discounted, with inappropriate disposition and monitoring.
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Despite being an effective analgesic for children with fractures, some clinicians may avoid prescribing ibuprofen due to its potentially harmful effect on bone healing. ⋯ Children with extremity fractures who are exposed to ibuprofen do not seem to be at increased risk for clinically important bone healing complications.
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Ovarian torsion is a rare but serious cause of pelvic pain in females. Making the diagnosis is important because misdiagnosis can lead to an ischemic ovary and subsequent infertility. ⋯ Although ovarian torsion is a challenging diagnosis, understanding myths surrounding the disorder may help emergency physicians consider it in unusual populations. If there is any clinical concern for ovarian torsion, a gynecologic consult may be helpful, even if imaging findings are not conclusive. Surgery remains the standard method for definitive diagnosis and treatment.
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Syncope is a transient loss of consciousness that is caused by a brief loss in generalized cerebral blood flow. ⋯ The syncope work-up should be tailored to the patient's presentation. Disposition should be based on the results of the initial evaluation and risk factors for adverse outcomes.