J Emerg Med
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Metformin toxicity can lead to profound shock and has a high mortality rate. Supportive care and enhanced elimination are the mainstays of therapy. Intermittent hemodialysis (HD) produces a higher clearance of metformin than continuous veno-venous hemofiltration or hemodiafiltration (CVVH/HDF). Nevertheless, CVVH/HDF has been proposed as an alternative in critically ill patients with the suggestion that hypotension may limit the use of HD. ⋯ Intermittent HD is feasible in metformin toxicity despite persistent shock and high-dose vasopressor support. Mean arterial pressures improved during the course of HD and high blood flow rates were tolerated.
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Randomized Controlled Trial
Comparison of Oral Ibuprofen and Acetaminophen with Either Analgesic Alone for Pediatric Emergency Department Patients with Acute Pain.
Ibuprofen (Motrin; Johnson & Johnson) and acetaminophen (APAP, paracetamol) are the most commonly used analgesics in the pediatric emergency department (ED) for managing a variety of acute traumatic and nontraumatic painful conditions. The multimodal pain management of using a combination of ibuprofen plus acetaminophen has the potential to result in greater analgesia. ⋯ We found similar analgesic efficacy of oral ibuprofen and acetaminophen in comparison with each analgesic alone for short-term treatment of acute pain in the pediatric ED, but the trial was underpowered to demonstrate the analgesic superiority of the combination of oral ibuprofen plus acetaminophen in comparison with each analgesic alone.
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Review Case Reports
ST-Elevation Myocardial Infarction in a Patient Having Dextrocardia with Situs Inversus.
Dextrocardia with situs inversus is a rare genetic condition in which the heart and internal organs are positioned on the opposite side of the body. Diagnosing and treating acute myocardial infarction correctly in a patient with dextrocardia is a difficult task. ⋯ We present the case of an acute anterior wall ST elevation myocardial infarction (STEMI) in a patient with dextrocardia with situs inversus diagnosed after a lead reversal electrocardiogram (ECG). The patient then successfully underwent percutaneous coronary intervention and subsequent multivessel coronary artery bypass grafting. We discuss the original diagnosis and decision-making, clinical features, ECG characteristics, and disposition of the patient, as well as a review of the relevant literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians must identify and recognize the typical ECG of dextrocardia, especially when presenting with pathology, as its identification can lead to proper diagnosis and treatment.
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Hemophilia and von Willebrand disease (VWD) are the most common congenital coagulation factor deficiencies. Patients with these disorders who experience bleeding complications are often initially managed in the emergency department (ED). ⋯ Emergency medicine providers must have an understanding of the pathophysiology, clinical presentation, and management strategies in order to optimally care for these complex patients.
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Hypermagnesemia is an often overlooked electrolyte abnormality that has a myriad of presenting symptoms. It has been observed after both accidental and intentional ingestions of magnesium-containing compounds, and as in the case presented, Epsom salts, which are primarily magnesium sulfate. ⋯ A 56-year-old man presented to the emergency department reporting weakness after an ingestion of Epsom salts used as a laxative and was found to be bradycardic and hypotensive. He subsequently developed altered mental status and respiratory depression necessitating intubation. His magnesium level was found to be > 3.91 mmol/L (> 9.5 mg/dL). He was given multiple doses of calcium gluconate and generous i.v. fluids with furosemide, with minimal improvement. However, his magnesium level corrected rapidly after initiation of dialysis, and 3 days later he was discharged home in good condition with normal neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Keeping a high level of suspicion for, and quickly recognizing, hypermagnesemia allows for prompt initiation of treatment, which can avoid significant hemodynamic or respiratory compromise. Mainstays of treatment are i.v. calcium and i.v. fluids. Loop diuretics may be given as an adjunct as well. Dialysis should be considered in cases of severe hypermagnesemia because it results in rapid correction of magnesium levels.