J Emerg Med
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Colchicine ingestion is rare but highly lethal. Patients usually die of multiorgan failure and cardiogenic shock. Colchicine is not only associated with depressed myocardial function but also with fatal heart rhythm disturbances, such as complete heart block, ventricular tachycardia, and asystole. While histologic changes of myocytes are well known, the mechanism by which colchicine affects cardiac impulse generation and conduction is not fully understood. ⋯ We present a case of colchicine ingestion with sinus bradycardia, marked sinus arrhythmia, and first- and second-degree heart block. A 10-year-old previously healthy boy was brought to the emergency department for the sudden onset of dizziness, abdominal pain, and vomiting after ingesting his grandfather's colchicine and furosemide. His symptoms improved with ondansetron and intravenous normal saline. However, because of the colchicine ingestion, he was admitted to the pediatric intensive care unit for observation. He first developed PR prolongation (∼4-30 h postingestion) followed by marked sinus bradycardia and sinus arrhythmia along with second-degree heart block (∼48-60 hours postingestion). The minimum heart rate was 40 beats/min. Marked sinus arrhythmia was observed, suggesting an increase in parasympathetic activity. His heart rhythm improved initially with less sinus arrhythmia followed by resolution of heart block. He was discharged home without any sequelae. Holter monitoring 1 week after discharge showed normal heart rate variability for age. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case provides novel insights into how colchicine may affect the heart's electrophysiology. Colchicine may increase the parasympathetic tone enough to cause sinus bradycardia and different degrees of heart block.
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Case Reports
Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?
Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. ⋯ End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.
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Oral lacerations represent a unique challenge for anesthesia in the emergency department. Many options exist for local anesthesia, but these options are often associated with pain from injections or anxiety from anticipated needle injection. ⋯ We introduce a novel and needleless approach to achieving local anesthesia for oral mucosa repair by dripping injectable lidocaine directly onto mucosal wounds prior to repair. This method is well tolerated and achieves appropriate anesthesia without undesirable side effects. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Dripped injectable lidocaine may be an alternative method for mucosal anesthesia in the pediatric population.
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Case Reports
Emergency Department Diagnosis of Septic Pulmonary Embolism due to Infectious Endocarditis Using Bedside Ultrasound.
Septic pulmonary embolism (SPE) is a rare disorder caused by metastasis of infectious thrombi to the lungs. Most commonly, this occurs as a result of infectious endocarditis. This clinical entity may easily be confused for more common and less mortal diagnoses such as pneumonia, bronchitis, or pulmonary embolism. ⋯ A 47-year-old woman presented in respiratory distress with a complaint of cough productive of rusty sputum, shortness of breath, and pleuritic chest pain. A bedside ultrasound suggested endocarditis and SPE. She was resuscitated and admitted to the hospital for surgical source control and continued i.v. antibiotics. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SPE is a rare disorder that may be easily missed but carries a high mortality rate. Additionally, the presence of the embolic phenomena makes the diagnosis of infectious endocarditis more attainable in the emergency department (ED). To our knowledge, this case is the first in which ED bedside ultrasound was used to make the diagnosis of SPE due to infectious endocarditis.