J Emerg Med
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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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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.
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Case Reports
Tracheal Irrigation Without Bronchoscopy as an Alternative Emergent Treatment of Blood Aspiration.
Tracheobronchial foreign body aspiration can cause mild symptoms but may also become dangerous enough to cause death. Bronchoscopy is the first choice for the diagnosis and the removal of aspirated foreign bodies. So, when bronchoscopy is not available, the situation might get challenging. ⋯ A 62-year-old man was waiting for emergent surgery for traumatic epidural hematoma in the Emergency Department (ED). Endotracheal intubation was performed for surgery and airway maintenance. However, oxygen saturation dropped and respiratory arrest was expected. As emergent bronchoscopy could not be performed, the emergency physician decided to irrigate the trachea by using 0.9% normal saline in the ED. After three rounds of irrigation, vital signs including oxygen saturation improved and the patient could undergo neurosurgical surgery. The patient was subsequently discharged with improved health. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bronchoscopy is the first choice for the treatment and diagnosis in cases of bronchial aspiration of blood, such as that caused by epistaxis. However, in emergency situations, such as deteriorating vital signs due to aspiration of life-threatening amounts of blood from epistaxis, using blind tracheal irrigation as an alternative tool when bronchoscopy is not available can help in achieving clinically acceptable results.
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Emergency medicine is a profession that requires good leadership skills. Emergency physicians must be able to instill confidence in both the staff and patients, inspire the best in others, have the enthusiasm to take on a surplus of responsibilities, and maintain calmness during unexpected circumstances. ⋯ Although some people do have a predisposition to lead, leadership can be both learned and taught. In this article, we provide medical students with the tools that will help them acquire those qualities and thus make them more desirable by program directors.
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Previous studies show that myocardial infarctions (MIs) occur most frequently in the morning. ⋯ These data suggest a potential shift in the circadian pattern of MI, revealing an afternoon predominance for both STEMI and NSTEMI subtypes.