J Emerg Med
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Cold anaphylaxis is a severe form of hypersensitivity reaction to cold temperatures. Such reactions include a spectrum of presentations that range from localized symptoms to systemic involvement. The condition can be acquired or heritable, although it may also be idiopathic. Treatment consists of second-generation H1 antihistamines, epinephrine, and supportive care. Prevention involves avoidance of known triggers, most commonly cold immersion due to environment or water exposure. ⋯ We report the case of a 34-year-old man with cold-induced urticaria/anaphylaxis who presented to our emergency department with hypotension and shortness of breath after exposure to cold air after getting out of a shower. He required two doses of intramuscular epinephrine and was ultimately started on an epinephrine infusion. He was admitted to the intensive care unit for anaphylaxis monitoring and was found to have a positive ice cube test, reinforcing the suspected diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Cold anaphylaxis is a potentially life-threatening phenomenon with specific testing. It is occasionally described in the emergency medicine literature. Providers should be aware of the potential for cold anaphylaxis as it can change patient guidance and alter management. This condition can also contribute to otherwise unclear and sudden decompensation in critically ill patients, as has been reported in cases of cold anaphylaxis induced by cold IV infusions.
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Review Case Reports
Low-Voltage Electricity-Associated Burn Damage of Lung Parenchyma: Case Report and Literature Review.
Electrical injuries are common in daily life. The severity of electrical injury depends on the electric current, and assessing electrical damage is difficult because there appears to be no correlation between skin burns and visceral injury. We report a case of bilateral lung injury with pulmonary hemorrhage after exposure to low-voltage electricity. ⋯ A 23-year-old man was shocked by a low-voltage (110 V) electric current while at work. He had temporary loss of consciousness and twitching in the extremities, but soon regained consciousness and spontaneously stopped twitching. Electrical burn wounds were discovered on his back and forehead. Dyspnea and hemoptysis were noted. A computed tomography scan of the chest revealed patchy infiltration and consolidation of both lungs. The patient received treatment of tranexamic acid and prophylactic antibiotics for electricity-induced lung injury and pulmonary hemorrhage. Resolution of chest radiograph abnormalities was recorded on day 7. The mild dyspnea ceased approximately 2 weeks later. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Electricity-induced lung injury should be considered in patients with electrical injury through a suspicious electrical current transmission pathway, respiratory symptoms, and corresponding imaging findings. Pulmonary complications can be serious and require early intervention.
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Despite the popular conception that ordering a urinalysis causes a significant increase in emergency department (ED) length of stay (LOS), there is little research on its actual impact. ⋯ Urinalysis does increase LOS, but blood testing increases it more, with additive effects when both are ordered.
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Bites from nonnative snakes are uncommon, accounting for 1.1% of envenomations reported to poison centers between 2015 and 2018. Here we discuss two monocled cobra (Naja kaouthia) envenomations resulting in respiratory failure. ⋯ A 30-year-old man and a 40-year-old man were bitten by their captive monocled cobras. At the first hospital, the first patient was mildly hypotensive, transiently bradycardic, and confused. He was intubated for respiratory distress. He was hypertensive to 211/119 mm Hg upon arrival to the second hospital. In the Emergency Department, cobra antivenom was administered. He was admitted to the medical intensive care unit (MICU) and had an additional bradycardic episode that corrected with atropine. He was extubated after 35 h. He was observed for an additional 9 h prior to going home, where he recovered without incident. The second patient developed abdominal pain, blurry vision, and dyspnea within 90 min of the bite. He was intubated at the first hospital. At the second hospital he received cobra antivenom and was admitted to the MICU. He was extubated after 9 h and discharged the following day with no further symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Envenomations after N. kaouthia bites are characterized by local tissue injury and various neurotoxic effects. Nonspecific signs and symptoms are common. Hematologic toxicity and cardiovascular manifestations are uncommon. Antivenom is the specific treatment for snake envenomation, but only certain antivenoms are indicated for N. kaouthia. Cholinesterase inhibitors may reduce toxicity from postsynaptic alpha toxins by increasing acetylcholine concentrations.
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A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy. ⋯ We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.