J Emerg Med
-
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.
-
Thyrotoxic hypokalemic paralysis is the hallmark of thyrotoxic periodic paralysis (TPP). TPP is a potentially deadly complication of hyperthyroidism that occurs because of rapid and dramatic intracellular shift of potassium. This transference results in severe hypokalemia and clinically manifests itself as muscle weakness or paralysis. This condition predominantly affects males of Asian descent, and its presentation can range from mild to severe, as seen in our case. ⋯ We present the case of a 15-year-old Asian-American male who presented to a tertiary-care pediatric emergency department complaining of generalized weakness and flaccid paralysis of his lower extremities. The differential for such a complaint is extremely broad, and the symptoms can result from etiologies arising from the cerebral cortex, the spinal cord, peripheral nerves, the neuromuscular junction, or even the muscles themselves. Our patient was found to have an extremely low serum potassium concentration, as well as an electrocardiogram that revealed a prolonged QT interval and right bundle branch block. The etiology of these abnormalities and the patient's symptoms was found to be undiagnosed and uncontrolled hyperthyroidism from Grave's disease, which resulted in this dramatic presentation of thyrotoxic hypokalemic paralysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This entity is common in Asia but still somewhat rare in the United States and other Western countries. Our case illustrates that careful history taking and a focused diagnostic evaluation, in conjunction with having an awareness of this disease, can help expedite diagnosis and management, as well as avoid unnecessary and potential harmful testing in the emergency department setting.
-
The oculocardiac reflex is a decrease in heart rate caused by ocular compression or traction upon the extraocular musculature. Multiple instances of this phenomenon have been described in anesthesia, trauma, craniofacial, and ophthalmology literature, but there is a sparsity of documentation in the emergency medicine literature. ⋯ We describe the observation and management of the oculocardiac reflex in a 26-year-old man with retrobulbar hematoma and intraocular trauma caused by a self-inflicted gunshot wound. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Prompt recognition of the oculocardiac reflex is important for the emergency physician given the common occurrence of craniofacial trauma and the potentially devastating consequences if not recognized and addressed.
-
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.
-
Insect venom anaphylaxis is a potentially life-threatening disorder. Transient coagulopathy in insect venom anaphylaxis is a rare phenomenon. ⋯ A 41-year-old man presented to the Emergency Department (ED) with hypotension after a run in a park. History and examination revealed signs of anaphylactic shock. A deranged coagulation profile with a normal platelet count led to the diagnosis of wasp sting anaphylaxis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Transient deranged coagulation profile with a normal platelet count may arise from insect venom anaphylaxis. This specific finding may aid the emergency physician in making a diagnosis of anaphylactic shock in an otherwise healthy patient presenting with shock with no apparent cause.