J Emerg Med
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More than a million people a year in the United States experience sepsis or sepsis-related complications, and sepsis remains the leading cause of in-hospital deaths. Unlike many other leading causes of in-hospital mortality, sepsis detection and treatment are not dependent on the presence of any technology or services that differ between tertiary and non-tertiary hospitals. ⋯ We observed higher sepsis mortality rates in non-tertiary hospitals, compared with tertiary hospitals. Because most patients who are treated for sepsis are treated outside of tertiary hospitals, and the number of patients treated for sepsis in non-tertiary hospitals seems to be rising, a better understanding of the cause or causes for this differential is crucial.
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Type II diabetes mellitus (DM) is an increasingly prevalent cause of morbidity and mortality among U.S. adults, with increasing prevalence in emergency department (ED) visits. Multiple medications, such as exenatide, a glucagon-like peptide-1 agonist, have been developed in the past decade to combat this growing problem. This medication is well documented to cause gastrointestinal upset and skin nodules at the injection site. However, currently no documented cases exist regarding manipulation of injection nodules causing increased absorption or reports demonstrating an increase in adverse drug reactions. ⋯ We report an interesting case of an adult male patient who likely experienced increased systemic absorption of exenatide by manipulating an injection nodule, which ultimately resulted in nausea, retching, diarrhea, and a tachycardic heart rate of 130-140 beats/min. These symptoms are known side effects of exenatide. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the high frequency of DM patients presenting to the ED, emergency physicians should be familiar with diabetic maintenance medications and their adverse reactions. Treating these side effects and properly educating patients can alleviate discomfort, prevent future adverse reactions, and decrease return visits to the ED.
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Capnocytophaga canimorsus is a bacterium of the normal oral flora of dogs and cats. Human infection is caused by animal bite but is rarely observed, mainly in immunocompromised patients. We present 2 cases of C. canimorsus infection that occurred in immunocompetent patients and caused multiorgan failure and in both cases severe neurologic involvement. ⋯ In the first case, we present a 69-year-old immunocompetent woman with septic shock derived from skin and soft tissue infection after a dog's bite. She developed ischemic necrosis evolving to gangrene of both forefeet and hands, infective aortic endocarditis, and neurologic involvement caused by large hemispheric hypodense lesions compatible with ischemic septical lesions. In the second case, we present a 65-year-old immunocompetent man with meningitis after a dog's bite. Despite antibiotic therapy, he developed neurologic clinical deterioration, with right sensitive hemisyndrome associated with lack of strength and motor skills of the right hand. Radiologic findings were consistent with the diagnosis of cerebritis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Clinicians should always be aware of this pathogen, both in immunocompromised and immunocompetent patients, and consider prophylactic antibiotics after exposure.
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Diplopia can be the result of benign or life-threatening etiologies. It is imperative for the emergency physician to be proficient at assessing diplopia and recognize when urgent referral or neuroimaging is required. ⋯ Unenhanced plain computed tomography (CT) of the head or orbits is largely not useful in the work-up of diplopia. Magnetic resonance imaging is preferred for ocular motor nerve palsies. Due to limited resources in the ED, patients with isolated fourth and sixth nerve palsies with the absence of other neurological signs on examination should be referred to Neurology or Ophthalmology for further work-up. All patients presenting with an acute isolated third nerve palsy should be imaged with CT and CT angiography of the brain to rule out a compressive aneurysm. Contrast-enhanced CT imaging of the brain and orbits would be indicated in suspected orbital apex syndrome or a retro-orbital mass, thyroid eye disease, or ocular trauma. CT and CT venogram should be considered in cases of suspected cavernous sinus thrombosis. In any patient over the age of 60 years presenting with recent (1 month) history of diplopia, inflammatory markers should be obtained to rule out giant cell arteritis.