J Emerg Med
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It is common practice for emergency physicians to give parenteral opioids for acute pain, however, some treating physicians have concerns that using parenteral opioids can lead to nausea and vomiting when used alone. Therefore, antiemetics are often given prophylactically with opioids for nausea and vomiting in the emergency department (ED). This systematic review evaluates the use of prophylactic antiemetics with parenteral opioids for the treatment of acute pain in the ED. ⋯ Based on the literature review, routine use of prophylactic antiemetics are not indicated with administration of parenteral opioids for treatment of acute pain in the ED, as nausea and vomiting are infrequent side effects. The recent literature clearly demonstrates that there are potential undesirable side effects from the use of antiemetics when using opioids. However, one subgroup of patients, those with a known history of nausea and vomiting after opioid use or a history of travel sickness, may benefit from the use of prophylactic antiemetic when being treated with parenteral opioids.
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Case Reports
Catecholaminergic Polymorphic Ventricular Tachycardia: Challenges During Resuscitation and Post-Cardiac Arrest Care.
Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare channelopathy involving cardiac calcium metabolism that often shows up at an early age with misleading clinical symptoms, such as emotion- or exercise-related syncope with a normal resting electrocardiogram. In addition, it might be the underlying cause of sudden cardiac arrest in children or young adults. The particular pathophysiology of CPVT makes it particularly challenging for both resuscitation and the subsequent intensive care management after return of spontaneous circulation (ROSC). ⋯ We describe a case of sudden cardiac arrest in an 11-year-old girl affected by CPVT, with a particular focus on the most challenging aspects of resuscitation and intensive care management in light of other experiences found in the literature. A warning about the prodysrythmicity of mild hypothermia induced in the context of post-ROSC targeted temperature management in this particular population of patients and its possible physiopathological basis are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: CPVT is a rare but potentially lethal cause of stress-related syncope and sudden cardiac arrest in children and young adults. The diagnosis of CPVT requires a high level of suspicion and an interdisciplinary approach, including some adjustments during resuscitation and post-cardiac arrest care.
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Many emergency department (ED) patients in diabetic ketoacidosis (DKA) are admitted to an inpatient intensive care unit (ICU), while ICU capacity is under increasing strain. The Emergency Critical Care Center (EC3), a hybrid ED-ICU setting, opened with the goal of providing rapid initiation of ICU care in the ED. ⋯ Management of patients with DKA in an ED-ICU was associated with decreased ICU and hospital utilization with similar safety outcomes. Managing rapidly reversible critical illnesses in an ED-ICU may help obviate increasing strain facing many health care systems.
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Type 1 diabetes mellitus (T1DM) is the most common form of diabetes mellitus in the pediatric population, with an estimated 500,000 children living with T1DM and an estimated 80,000 new cases each year in the United States. Ophthalmologic complications of diabetes are common in adult patients and those with longstanding disease, but can also be seen in patients with a recent diagnosis, even among the pediatric population. ⋯ We present the case of a 13-year-old girl with recently diagnosed T1DM who presented to the pediatric emergency department with acute onset of bilateral blurry vision due to cataract formation. Prompt recognition of the condition and ophthalmologic consultation allowed for timely diagnosis and restorative surgery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of the potential for cataract formation in pediatric patients with T1DM, as well as the fact that it may be the first presenting sign of the disease. Furthermore, emergency physicians should be aware that pediatric patients who present with severe T1DM, either with extremely high hemoglobin A1c or glycemic blood levels, are at increased risk for cataract formation and should be evaluated for subtle signs of cataract formation even in the absence of obvious cataracts. We also discuss the pathophysiologic theories of cataract formation in patients with T1DM.
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Patients with ST elevation on electrocardiogram (ECG) could have ST elevation myocardial infarction (STEMI) or pericarditis. Spodick's sign, a downsloping of the ECG baseline (the T-P segment), has been described, but not validated, as a sign of pericarditis. ⋯ Spodick's sign is statistically associated with pericarditis, but it is seen in 5% of patients with STEMI. Among other findings, ST depression, III > II, and absence of PR depression were the most discriminating.