J Emerg Med
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Cardiac tamponade is a life-threatening disease with a high mortality rate. Its clinical manifestations depend on the length of time over which pericardial effusion accumulates. Among those, hiccups are rarely reported. ⋯ We present a 48-year-old man who came in with a chief complaint of persistent hiccups and later had hypotension and dyspnea at the emergency department. Electrocardiogram revealed diffuse ST elevation with mildly elevated cardiac enzymes. Echocardiography showed massive pericardial effusion, implying cardiac tamponade. Catheter pericardiocentesis was performed and massive pericardial effusion was drained. Hiccups subsided after the procedure and the patient recovered uneventfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To the best of our knowledge, this is the first case of cardiac tamponade with the presenting manifestation of persistent hiccups. Emergency physicians should stay vigilant when approaching those patients with unexplainable prolonged hiccups.
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Venous thoracic outlet syndrome (VTOS) results from compression and thrombosis of the axillosubclavian vein. In primary effort thrombosis, a subtype of VTOS, chronic repetitive compression injury of the axillosubclavian vein leads to scarring, stenosis, and eventually, thrombosis. This is a rare manifestation of an upper extremity deep vein thrombosis. ⋯ A 23-year-old male student without significant past medical history presented to our Emergency Department with a complaint of intermittent swelling and discoloration of his upper right arm. His symptoms had been present for the past year and had worsened over the past few weeks. Swelling was associated with overhead use of the arm. There is no family history of clotting disorders. A computed tomography angiogram of the chest with upper extremity runoff showed findings consistent with VTOS. The patient was discharged with an urgent referral to Vascular Surgery. Within 2 weeks, he underwent multiple surgical procedures and was initiated on anticoagulation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: VTOS usually presents in patients who do not have commonly recognized prothrombotic risk factors. Emergency physicians should include this diagnosis in their differential because good functional outcomes rely on early diagnosis and prompt initiation of treatment. In addition, emergency physicians must refer these patients to vascular surgeons, as most will require surgical management.
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Flecainide is a class Ic antidysrhythmic agent used to prevent and treat both ventricular and supraventricular tachycardias, including atrial fibrillation, atrioventricular nodal re-entrant tachycardia, and Wolff-Parkinson-White syndrome. Flecainide can cause serious side effects, including cardiac arrest, dysrhythmias, and heart failure. Despite its growing use, the presenting signs and symptoms of flecainide toxicity are not familiar to most clinicians. In particular, our patient's particular presentation of acute kidney injury (AKI) resulting in flecainide accumulation is high risk for missed diagnosis in the emergency department. ⋯ A 58-year-old woman presented with altered mental status and hypoxia that was later found to be secondary to sepsis. Medical history was notable for atrial fibrillation, for which she was on flecainide. Laboratory results were notable for hypokalemia and an AKI. Her wide complex tachycardia on admission was ultimately attributed to flecainide toxicity in the setting of AKI. Six days after presentation, it was found that her flecainide level was in the toxic range at 2.02 μg/mL (normal range 0.20-1.00 μg/mL, toxic >1.50 μg/mL). WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Flecainide intoxication is rare but serious due to the potential for cardiogenic shock. Its diagnosis can be difficult, as the flecainide serum level may take days to result. This case demonstrates the necessity of keeping flecainide toxicity on the physician's differential for patients who are taking the drug, as well as what electrocardiogram findings suggest it as the etiology. Treatment can be lifesaving if initiated promptly.
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In 2010, the American Heart Association recommended that postcardiac arrest care should be included in the chain of survival to reduce permanent neurological damage, improve quality of life, and reduce health care expenses of postcardiac arrest care. ⋯ For patients with IHCA, the overall short-term survival improved significantly after modification of the chain of survival. Younger patients and patients with CHD had better long-term survival.