J Emerg Med
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Opioid overdose deaths in 2021 were the highest ever, driven by fentanyl and polysubstance use. ⋯ Most participants had UDS specimens containing multiple substances; a high proportion had fentanyl, stimulants, and buprenorphine. Regional differences were noted. Given the increased risk of death with fentanyl and polysubstance use, ED providers should be providing risk reduction counseling, treatment, and referral.
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The detrimental effects of hyperoxia exposure have been well-described in patients admitted to intensive care units. However, data evaluating the effects of short-term, early hyperoxia exposure in patients intubated in the prehospital setting or emergency department (ED) have not been systematically reviewed. ⋯ There is a paucity of data that examined the effects of severe hyperoxia exposure in the acute, post-intubation phase of the prehospital and ED settings. Further research with standardized definitions is needed to provide more detailed guidance regarding early oxygen titration in intubated patients.
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Review Case Reports
Spontaneous Pneumocephalus: A Case Report with a Literature Review.
Pneumocephalus is defined as gas in the intracranial space. Common causes include head trauma, surgery, and diagnostic/therapeutic procedures resulting from the direct disruption of the dura. Spontaneous or nontraumatic pneumocephalus is an uncommon condition, often caused by infection, either due to insidious disruption of the dura or gas-forming pathogens. ⋯ Herein, we report a rare case of spontaneous pneumocephalus associated with meningitis in a patient who received conservative treatment without surgical intervention. Blood culture revealed group A streptococcus. The pneumocephalus subsided gradually with antibiotic treatment, and no neurological deficits remained. A follow-up brain computed tomography scan showed the absence of pneumocephalus, but it showed progressive hydrocephalus. The patient was discharged on the 21st day of hospitalization. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous pneumocephalus associated with meningitis is rare. It should always raise the suspicion of meningitis and prompt suitable treatment. Emergency physicians should always be vigilant for this particular possibility on brain computed tomography.
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Cervical subluxation is a broad class of injuries in which there are degrees of misalignment of vertebral bodies in relationship to adjacent vertebra. Atlantoaxial rotatory subluxation (AARS) is a subtype of cervical subluxation resulting from exaggerated rotation of the C1-C2 complex. Inflammatory, infectious, post-surgical, and traumatic etiologies are recognized and well-described. AARS is predominantly seen in children and occurs rarely in adults. ⋯ We submit the case of an otherwise healthy adult male patient presenting to the emergency department with strangulation-induced C1-C2 subluxation with a rotational component that was treated at the bedside by neurosurgery with closed reduction. Why Should an Emergency Physician Be Aware of This? Clinicians must consider a broad range of serious pathologies in a patient presenting with torticollis, especially in the setting of strangulation. Although extremely rare in adults, AARS must be considered in the differential diagnosis, as early identification increases the likelihood of successful nonoperative treatment.
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Case Reports
Oral and Transdermal Rivastigmine for the Treatment of Anticholinergic Delirium: A Case Report.
Anticholinergic toxicity is a common cause of delirium in emergency department patients. The standard antidotal treatment for anticholinergic toxicity is physostigmine. Physostigmine functions as a reversible acetylcholinesterase inhibitor that readily crosses the blood-brain barrier. Rivastigmine is another member of this class currently approved for the treatment of Alzheimer's disease and Parkinson's disease. Rivastigmine also crosses the blood-brain barrier and has been found to be effective in the management of anticholinergic toxicity in limited case reports. ⋯ A 61-year-old women presented to the emergency department via emergency medical services with altered mental status and a Glasgow Coma Scale score of 8 out of 15. She was found down near multiple medication bottles, including diphenhydramine and dicyclomine. Her physical examination was consistent with anticholinergic toxicity with mydriasis, obtundation, and warm flushed skin. In addition to standard resuscitation, she received two doses of rivastigmine 3 mg via nasogastric tube. After the second dose she was alert and oriented. She was admitted to the intensive care unit and had a rivastigmine patch applied. She was deemed back to her baseline 27 h after presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although the standard antidotal treatment for anticholinergic toxicity is physostigmine, there is a national shortage of this medication. In the absence of this standard antidote, it is reasonable for emergency physicians to use rivastigmine as an alternative treatment. This can be delivered orally or via nasogastric tube with dosing each hour until resolution of symptoms. Alternatively, in consultation with toxicology, it may be reasonable to use transdermal rivastigmine, as it provides consistent drug absorption for 24 h.