J Emerg Med
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A severe baclofen intoxication is a potentially life-threatening condition. It is associated with coma and can cause brainstem reflexes to disappear, simulating a brain death-like condition. When given intensive supportive care and time, patients can recover without residual neurological damage. ⋯ We present a case of a patient with known spastic cerebral palsy who was found unresponsive with no signs of breathing. He was brought to the Emergency Department, intubated, put on the ventilator, and hemodynamically stabilized. Brainstem reflexes were absent and he appeared brain dead. During the secondary survey, an intrathecal baclofen pump was found at his left lower abdomen, with a swelling next to it. A baclofen intoxication was suspected. He was admitted to the Intensive Care Unit, and after 72 h of supportive care complete neurological recovery was achieved. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Systemic baclofen intoxication can simulate a brain death-like condition. There is no reliable correlation between baclofen serum levels and central nervous system depression in case of an intoxication. It is important for emergency physicians to recognize a baclofen intoxication as a possible cause of coma and absent brainstem reflexes. Recuperation is spontaneous and can follow within days without residual damage. Because these patients may be brought in after a period of apnea or cardiopulmonary resuscitation, focus may be on post-hypoxic encephalopathy considerations instead of a possible baclofen intoxication.
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Patients often present to the emergency department with paroxysmal atrial fibrillation. There is increasing recognition that, in a subset of patients, certain clinical triggers mediated via the autonomic nervous system may precipitate episodes of atrial fibrillation. Although identification of these triggers may be critical for prevention of future episodes, they may be overlooked by treating physicians. ⋯ We describe an otherwise healthy 64-year-old physician who presented on two separate occasions to the emergency department with atrial fibrillation. He was electrically cardioverted successfully into normal sinus rhythm and discharged without medications both times. The patient ultimately recognized that both episodes occurred in the setting of strenuous exercise followed soon after by ingestion of cold water. Since avoiding this sequence he has not had any episodes of atrial fibrillation in the ensuing 7 years. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians often encounter patients who present with paroxysmal atrial fibrillation, some of whom may have autonomic triggers or trigger sequences that precipitated it. Although our single case report cannot prove that the sequence described caused the atrial fibrillation, we hope the case can serve to highlight the increasing awareness that, in a subset of patients with paroxysmal atrial fibrillation, identification of specific triggers could be critical in prevention and should be sought.