J Emerg Med
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Fournier gangrene (FG) is a rare, life-threatening infection that can result in significant morbidity and mortality, with many patients requiring emergency department (ED) management for complications and stabilization. ⋯ FG requires a high clinical level of suspicion, combined with knowledge of anatomy, risk factors, and etiology for an accurate diagnosis. Although FG remains a clinical diagnosis, relevant laboratory and radiography investigations can serve as useful adjuncts to expedite surgical management, hemodynamic resuscitation, and antibiotic administration.
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More than 1500 scorpion species exist worldwide, with a few scorpion species potentially lethal to humans. About 1 million stings annually result in >3000 deaths, but the incidence and mortality vary greatly by species and location. Physicians working internationally must recognize that resulting toxidromes vary significantly by region. Over the past few decades, South America has reported relatively few deaths and low case mortality rates from envenomations. In Guyana, a small tropical country on its northeast coast, they have been extremely rare. A sudden fatal case cluster suggests an extension of the black scorpion's habitat, an increase in venom toxicity, or both. ⋯ During a 12-month period, Guyana experienced 3 deaths, including 1 adult, from black scorpion (Tityus obscurus) envenomation. The 30-year-old man and 2 young children experienced the same symptom complex, initially appearing well except for pain at the sting site. They soon developed persistent emesis and leukocytosis. All were flown from remote jungle areas to the only public tertiary care hospital where they received maximal available medical support. They gradually developed profound cardiopulmonary failure requiring ventilation and, eventually, dysrhythmias. None had hyperglycemia or pancreatitis, and they had no neurologic abnormalities until developing progressive obtundation immediately before intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Scorpion envenomation symptoms, outcomes, and treatment are geographically specific. Patients benefit when clinicians recognize the worldwide variations in grading systems and treatment options, which we discuss and compare to our patients.
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Diagnosis of acute osteomyelitis in young children can be challenging due to the lack of specific clinical signs and symptoms. Prompt diagnosis and treatment is essential to prevent complications and to improve long-term prognosis and reduce the need for operative intervention. Point-of-care ultrasound (POCUS) may be a useful tool to detect early changes associated with osteomyelitis. ⋯ A 26-month-old boy presented with 6 days of fever and 3 days of focal pain over the right anterior lower ribs without swelling, erythema, or bony deformity, and negative chest x-ray study. A POCUS was performed by the ultrasound fellows and revealed deep soft tissue swelling, periosteal elevation, and increased vascular flow with color Doppler. The patient was admitted to the pediatric service with infectious disease consultation and started on antibiotics. Magnetic resonance imaging confirmed the diagnosis of a right seventh anterior rib osteomyelitis, and the patient subsequently improved and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In this case, the use of POCUS in the emergency department heightened the suspicion for acute osteomyelitis in a rare location and guided early diagnosis and treatment.
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Early recognition of sepsis remains a major challenge. The clinical utility of the Quick Sepsis-Related Organ Failure Assessment (qSOFA) score is still undefined. Several studies have tested its prognostic value. However, its ability to diagnose sepsis is still unknown. ⋯ qSOFA offered high specificity for the prediction of sepsis and adverse outcomes. However, its low sensitivity does not support widespread use as a screening tool for sepsis. NEWS outperformed qSOFA for prediction of adverse outcomes and screening for sepsis.
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Children presenting to pediatric emergency departments (EDs) are frequently given enemas for relief of constipation symptoms; there is very little literature guiding solution selection. ⋯ There was no significant difference in reported stool output produced by sodium phosphate, soap suds, and pink lady enemas in children treated in an ED. Further study via randomized controlled trials would be beneficial in guiding selection of enema solution.