J Emerg Med
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Transjugular intrahepatic portosystemic shunt (TIPS) alters portal blood flow and may impact drug metabolism and bioavailability. However, little evidence has been published to provide guidance on medication alterations after TIPS procedures. ⋯ We report a patient who developed phenytoin toxicity requiring a prolonged readmission after a TIPS procedure. It is likely that the TIPS procedure altered phenytoin metabolism and led to toxicity in this patient. Phenytoin is an antiepileptic drug that is primarily eliminated by hepatic metabolism. It is possible that phenytoin toxicity may occur after TIPS, and that decreased dose requirements may be a durable effect of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TIPS is now the most common portal hypertension decompressive procedure performed by interventional radiologists and has become the primary portosystemic shunt (surgical or percutaneous) performed in the United States. Patients with a history of TIPS procedures commonly present to tertiary- and quaternary-care emergency departments with complex clinical presentations. Greater familiarity with the potential effects of TIPS on drug metabolism may help emergency physicians prevent adverse drug effects and optimize clinical outcomes.
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Pediatric clonidine ingestions frequently result in emergency department visits and admission for cardiac monitoring. Detailed information on the clinical course and specifically time of vital sign abnormalities of these patients is lacking. ⋯ In this study of patients at a pediatric tertiary referral center, pediatric patients with report of clonidine exposures were likely to exhibit altered mental status and frequently develop vital sign abnormalities. Naloxone exhibited some effectiveness; given its wide safety margin, high-dose naloxone should be used in critically poisoned non-opioid-dependent patients. Because adolescents are much more likely to ingest their own clonidine medication, counseling with parents and other caregivers regarding safe medication storage is paramount.
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Iatrogenic femoral artery pseudoaneurysm formation after intervention of the femoral artery may present weeks after intervention. We report a case of a patient with delayed pseudoaneurysm diagnosis that was ultimately diagnosed with bedside ultrasound. Importantly, our case demonstrates a patient who had a left-sided atherectomy and angioplasty with microcatheter access of the right femoral artery. ⋯ A 68-year-old man with multiple comorbidities presented to the Emergency Department (ED) with right inguinal pain, swelling, and overlying skin changes 17 days after an interventional radiology-guided left-sided femoral artery atherectomy and angioplasty. His first postoperative ED visit at an outside hospital led to the diagnosis of a hematoma vs. abscess, with attempted bedside drainage. On presentation to our ED, a bedside ultrasound confirmed arterial pseudoaneurysm formation of the right femoral artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients presenting with the constellation of symptoms after arterial site intervention of either side, iatrogenic pseudoaneurysm should be in the differential. Although the patient had atherectomy and angioplasty of the left femoral artery, it is important to highlight that both femoral arteries were accessed during intervention, and thus, both sites are at risk for pseudoaneurysm formation. Emergency sonography can be a useful tool to diagnose, expedite treatment, and avoid potentially harmful invasive procedures in patients presenting with pain and swelling after arterial site intervention.
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Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. ⋯ These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.
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The interval from patient arrival to triage is arguably the most dangerous time a patient spends in the emergency department (ED), as they are an unknown entity until assessed by a health care professional. ⋯ DTT is an important variable affecting patient safety. Given site-specific factors, replication across additional centers is necessary. Additional research evaluating factors affecting DTT, different triage paradigms, and quality improvement interventions should be undertaken.