J Emerg Med
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Review Case Reports
Refractory Hypotension Caused by Prazosin Overdose Combined With Acetaminophen and Naproxen Toxicity: A Case Report and Review of the Literature.
Pediatric exposure to prazosin is unusual because it is most commonly indicated for the treatment of hypertension. Prazosin's increase in popularity as a treatment for posttraumatic stress disorder makes it important for emergency physicians to be aware of how to manage potential toxic ingestion because of prazosin overdose. ⋯ A 16-year-old, 76-kg female presented after ingesting 110 mg of prazosin, 209.3 g of acetaminophen, and 55 g of naproxen. She was admitted to the pediatric intensive care unit for rapidly deteriorating hypotension (lowest blood pressure 47/19 mm Hg) refractory to aggressive fluid resuscitation and infusions of epinephrine and norepinephrine each at 0.5 mcg/kg/min. Stabilization of blood pressure was eventually achieved, and associated with use of a vasopressin infusion of 0.004 units/kg/min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because of the increasing exposure of children to prazosin, clinicians should be aware of the pharmacology behind alpha-1 antagonist overdose and consider treatment options, such as vasopressin, when hypotension is resistant to standard fluid and catecholamine therapy.
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Currently, the role of ultrasound in diagnosing superficial abscesses is well validated, however, its role for deep space infections and intramuscular pathology is limited. Distinguishing between simple cellulitis and abscess is critical for emergency physicians (EP), as the treatment is very different. Management of cellulitis relies on antibiotic therapy, whereas abscess treatment requires incision and drainage. It is important that EPs can accurately distinguish between the two entities. ⋯ We report a case of a 41-year-old man with a history of high blood pressure and poorly controlled diabetes who presented with right lateral thigh redness, warmth, and tenderness. A point-of-care ultrasound (POCUS) of the patient's right lateral thigh with a high-frequency linear (8 MHz) ultrasound probe showed a 2.93 × 3.38 × 6.0-cm complex fluid collection deep to the fascial plane, approximately 3.0 cm from the skin surface, that contained mixed echogenicities with posterior acoustic enhancement consistent with an intramuscular abscess of the vastus lateralis. The patient was diagnosed with pyomyositis of his vastus lateralis. He was started on vancomycin and admitted to the surgical service for antibiotic treatment and surgical drainage. WHY SHOULD EMERGENCY PHYSICIANS BE AWARE OF THIS?: This case demonstrates that the use of POCUS by EPs can facilitate the rapid recognition and treatment of a disease that is challenging to diagnose on physical examination and can be potentially life-threatening if missed. EPs can consider performing a POCUS when evaluating skin infections to ensure rapid diagnosis and appropriate medical care for a potentially severe condition.
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Patients presenting to the emergency department (ED) with psychiatric complaints often require medical screening to evaluate for a medical cause of their symptoms. ⋯ Based on available literature, physician experts developed 7 recommendations. For a patient with known psychiatric disease presenting with symptom exacerbation, medical screening should include a full medical and psychiatric history, a targeted physical examination, and a mental status examination. Urine toxicology screening and nonurine drug screen laboratory testing should not be routinely performed. Additional screening tests may be valuable for patients with new-onset psychiatric symptoms who are ≥65 years of age, are immunosuppressed, or have concomitant medical disease. However, additional studies on this topic with more rigorous methodology must be conducted to establish definitive guidelines.
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Compartment syndrome is often considered in patients with long-bone fractures and soft-tissue injuries, but is not as commonly associated with a period of unconsciousness. ⋯ A 65-year-old man was brought to our emergency department (ED) because he had lost consciousness for an unknown amount of time after snorting heroin. He had severe pain in his upper right arm. Physical examination revealed right arm edema, paresthesia, tenderness, and firmness to palpation. During the ED assessment, the patient began to experience pain in his right hip to a degree exceeding examination findings. We considered compartment syndrome affecting his upper arm as well as his gluteal muscles. The patient was taken to the operating room for fasciotomy. The triceps muscle was found to be bulging out of the compartment, demonstrating advanced compartment syndrome. A posterior approach to the hip allowed the gluteal sling and the fascia to be released, eliminating tension on the gluteus medius/minimus and gluteus maximus compartments. With physical therapy, the patient regained full flexion and extension in his arm at the elbow, partial extension of his wrist, and range of motion and strength in his hip. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: If not recognized, compartment syndrome can jeopardize limb and life. It should be considered in patients experiencing inordinate pain, especially if they were found unconscious at the incident scene. Pressure-induced ischemia can impair muscle function within hours. If it is not relieved with fasciotomy, the patient can sustain irreversible functional loss.