J Emerg Med
-
Case Reports
High-Dose Insulin for Toxin Induced Cardiogenic Shock: Experience at a New High and Overview of the Evidence.
High-dose insulin therapy is an effective treatment for cardiogenic shock caused by the overdose of particular medications. Other treatment options are usually of limited benefit. Consensus suggests that early initiation improves efficacy. No ceiling effect has been established at doses in the general range of 0.5-10 units/kg/hour. ⋯ A 79-year-old man presented in cardiogenic shock after an intentional overdose of numerous cardioactive medications 10 days after experiencing myocardial infarction. A high-dose insulin infusion was commenced. This was titrated up to a maximum of 20 units/kg/hour (1600 units/hour) and sustained for 32 h (61,334 units total). Minimal adverse events were seen despite this exceptional infusion rate (3 episodes of hypoglycemia and 2 episodes of hypokalemia). Concurrent catecholamine support was used, and cardiovascular function was maintained until all support was withdrawn 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are pivotal to the successful initiation/up-titration of high-dose insulin therapy. They must balance the potential for treatment failure with other treatment options, mitigate against adverse events in the initial phase of therapy, and coordinate care between other hospital specialties. This case shows that the relative safety and efficacy was extended to an infusion rate of 20 units/kg/hour, the highest recorded in the published literature. This information may help guide treatment of similar cases in the future.
-
Effective management of poisoning requires adequate stocking of antidotes in hospitals that provide emergency care. Antidote stocking represents a major challenge to hospitals all over the world, including Kuwait. ⋯ Public and private hospitals in Kuwait have suboptimal stocks of essential antidotes. There is an urgent need to develop expert consensus guidelines to assist hospitals to reduce costs and improve patient care by adequately stocking essential antidotes.
-
Transfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes. ⋯ The CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.
-
Improvement in hypertension control in the insured, adult population could improve morbidity and mortality associated with hypertension in the United States. The emergency department (ED) is a potential site of intervention, where individuals are diagnosed with asymptomatic hypertension and referred to primary care. ⋯ Individuals without a recent primary care visit or who visit the ED frequently are at higher risk of nonadherence to follow-up for hypertension, despite medical insurance. Insurance status may not overcome individual level barriers to follow-up.
-
Marijuana is a commonly used substance in the United States for both recreational and medicinal purposes. Detrimental health-related effects of marijuana continue to be a source of controversy. ⋯ We describe a case of a woman who presented to the emergency department with acute right upper and lower extremity weakness and altered speech after accidental unknown ingestion of food containing tetrahydrocannabinol (THC). This is a unique case in that we could find no other published report of focal weakness or motor stroke symptoms occurring in the setting of THC ingestion. We will discuss in detail the patient's medical history and timeline of events leading to her presentation to the emergency department. Marijuana contains the psychoactive substance THC and is becoming more commonly used for medicinal and recreational purposes in the United States and abroad. The use of THC is associated with changes in levels of consciousness, perception, and several other physiologic processes. We hope to increase awareness through this case report of accidental THC use by a female patient that resulted in a stroke code and potentially could have led to the use of tissue plasminogen activator. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To the best of our knowledge, focal neurologic deficits associated with THC use have not been reported in the published literature. We hope that this knowledge will encourage physicians to consider THC intoxication as a cause of new onset extremity weakness.