Frontiers in Emergency Medicine (E-Journal)
Not a member yet
430 research outputs found
Sort by
A 58-Year-Old Woman with Weakness and Shortness of Breath
Get PDFThe patient was a 58-year-old woman with a history of mitral valvuloplasty, presenting to the emergency department (ED) due to weakness and shortness of breath. Her vital signs were stable. The patient’s electrocardiogram (ECG) is presented in figure 1. What is the correct interpretation of this ECG?
Sinus dysrhythmia
Paroxysmal atrial tachycardia with variable AV node block
Atrial flutter with variable AV node block
Sinoatrial block
Atrial fibrillation with normal ventricular rate
The baseline rhythm of this ECG shows an irregularity at the first glance that is repeated without any specific pattern. After considering this irregular abnormal pattern, in the next step, the heartbeat in this ECG should be calculated, taking into account the irregular base rhythm, about six seconds of the ECG should be considered, and the number of complete QRS complexes should be counted in this period. The resulting number should be multiplied by ten in order to estimate the heart rate in a minute. In this patient, the heart rate was about 90 beats per minute. So far, we have an irregular abnormal rhythm in the ECG. Differential diagnosis of this condition in the ECG varies based on the wide or narrow QRS complexes. A narrow QRS complex is a sign of the natural ventricular depolarization, and several rhythms with a natural rate (60-100 beats per minute) can have irregular QRS intervals. In the case of irregular abnormal rhythms, normal rates, and narrow QRS complexes, there are various differential diagnoses, some of which are mentioned in the multiple choice answer to this question. In the following, after mentioning the electrocardiographic characteristics of each of the rhythms mentioned in the question and their simultaneous assessment in this ECG, we will reach the correct answer
Pain Relieving Effect of Sublingual Glycerol Trinitrate in Renal Colic: a Randomized Placebo-Controlled Trial
Get PDFIntroduction: Renal colic is caused by colicky spasms of ureters. As has been shown in previous experiments, glycerol trinitrate (TNG) can inhibit these muscular spasms. Objective: This study was performed to assess the pain relieving effect of TNG among patients referred due to renal colic pain to the emergency department (ED). Methods: This study is a randomized, placebo-controlled study on 60 patients with renal colic who were referred to the ED, who were diagnosed clinically to have renal colic, and their pain was more than 5 based on a visual analogue scale (VAS). The patient's pain was recorded at the moment of clinical diagnosis, and each one received one capsule, either 0.4 mg TNG or placebo, plus a 100 mg indomethacin suppository. The pain score was re-assessed after 5 and 30 min. The values were recorded and compared using SPSS-16 software. Results: Sixty patients with a mean age of 35.75 ± 11.99 years were enrolled (73.3% male). Patients in the two groups were matched for age (p = 0.290), sex (p = 0.559), and the presence of microscopic hematuria (p = 0.292). Pain relief from the start point until the end of the intervention was statistical different in all studied patients (p < 0.05); but the comparison between the two groups showed no significant difference in this regard (p = 0.440). Conclusion: It is likely that adding TNG to an indomethacin suppository had no significant effects on better pain management of patients referred with renal colic to the ED
Atypical Presentation of Acute Appendicitis: A 32-year-old Man with Gastroenteritis Symptoms; an Educational Case
Get PDFIntroduction: Appendicitis is a common condition that almost always requires emergency surgery. The diagnosis is clear when the patient presents with classic symptoms. However, presentation may be variable due to variations in the position and length of the appendix. Case presentation: Here, we report a 32-year-old man who presented with diarrhea and lower abdominal pain. Physical examination revealed a generalized abdominal tenderness, more prominent in the lower abdomen, including the right and left quadrants. Abdominal ultrasound failed to show any findings supportive of the diagnosis of appendicitis. Further investigation with abdominopelvic computed tomography (CT) with intravenous and oral contrast revealed retrocecal appendicitis. The patient was discharged home after a non-complicated appendectomy. Conclusion: Emergency physicians should be aware that appendicitis may not always show up with a typical presentation and they should consider the possibility of appendicitis when evaluating an acute abdomen to prevent any delay in diagnosis of atypical presentations
A 26-Year-Old Man with Headache
Get PDFIn this case, changes are made to the shape or amplitude of ECG complexes change alternatively. In the most common form, alternative changes can be viewed better in QRS complexes and in mid precordial leads. These alternative changes can be seen simultaneously in every other QRS complex and T wave. This means that in one beat the amplitude or shape of QRS complexes and T wave are normal and in the next beat the amplitude or shape of QRS complexes and T wave change. Since at times QRS complexes get closer, then they collapse and overlap and after that they gain distance from each other again. The answer to this ECG is a heterotropic transplanted heart.
 
Dr. Shervin Farahmand: Head of Emergency Medicine Department at Tehran University of Medical Sciences
Get PDFHypertonic Saline in the Treatment of Hemorrhagic Shock
Get PDFContext: The present review discusses different studies about the treatment of hemorrhagic shock (HS) with hypertonic saline (HTS). Evidence acquisition: We have searched the title in the most popular databases containing recent meta-analysis or randomized clinical trials (RCTs). Results: We introduce the hemodynamic effects and mechanisms of action of HTS in HS. Evidence in this field shows controversial results. There are some data supporting the potential benefits of HTS infusion in HS. The goal of research in this field is to identify the best therapy in HS with the least mortality. Conclusion: Our conclusion shows that although HTS can decrease inflammatory response during HS, it can attenuate hypercoagulability and cause complications. There are no data supporting less mortality while treatment with HTS versus other fluids in HS
Fever and Flank Pain in a Diabetic Woman; a Case of Emphysematous Pyelonephritis
Get PDFCase presentation: A 55–year-old diabetic woman presented to the emergency department with a complaint of nausea, vomiting, right upper abdominal pain, and fever with chills since 10 days. She revealed a 10-year history of poorly controlled diabetes on oral agent and kidney stones. On examination, the patient was found to be febrile (39 ℃) with tenderness in the right renal angle. Laboratory data has revealed the following findings: blood sugar (BS: 480 mg/dl), HbA1C: 13%, complete blood count (white blood cells (WBC): 13,900; polymorphonuclear leukocytes (PMN): 80%; lymphocytes: 18%; hemoglobin: 12 g/dl; and platelet: 118,000), blood urea nitrogen (BUN): 79 mg/dl, creatinine (Cr): 2.3 mg/dl, and erythrocyte sedimentation rate (ESR): 103 mm in 1 h. The urine analysis revealed 12–13 WBCs, 7–8 red blood cells (RBCs), and several bacteria. Urgent ultrasound indicated a heterogeneous mass in with focal echoes suggesting intraparenchymal gas, along with gross hydronephrosis and numerous stones, in the right kidney. The patient was treated with hydration, insulin, and intravenous imipenem 500 mg twice daily (adjusted with her creatinine). After 48 h, blood culture report was negative, whereas urine culture revealed presence of imipenem sensitive Citrobacter. Computed tomography (CT) scan without contrast indicated an enlarged, edematous right kidney with multiple air bubbles and air fluid levels. Based on the clinical and radiological findings, diagnosis was confirmed and right urgent nephrectomy was performed after 36 h of admission. The histopathology of the removed kidney revealed acute or chronic inflammation and necrosis, extending to the perinephric fat. The patient was discharged without any major complication after a 14-day hospital stay.
Learning points: Emphysematous pyelonephritis (EPN) is an acute, severe, and gas producing necrotizing bacterial infection that affects the renal parenchymal and surrounding tissues. The predisposing factors include: diabetes mellitus, urinary tract obstructions, and immune incompetence. Diabetes mellitus is the most commonly associated factor and up to 90% of the patients report uncontrolled diabetes mellitus. Bilateral renal involvement and obstruction has been observed in 5% and 30% of the patients, respectively. The most common pathogen causing EPN is Escherichia coli. Other pathogens have been reported including Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. Several factors contribute in the pathogenesis of EPN including high levels of glucose inside the tissues, gas forming bacterial infection, impaired vascular blood supply, reduced host immunity, and obstruction in the urinary system. Clinical manifestations are similar to acute pyelonephritis, including fever, nausea, vomiting, and flank pain; however, often they do not respond to the medical treatment. Laboratory investigations often reveal leukocytosis with a shift to the left, thrombocytopenia, and elevation of the serum creatinine levels. As aforementioned, urine analysis reveals WBCs, RBCs, and several bacteria. The diagnosis is confirmed by radiological imaging. A plain abdominal X-ray can be more specific than the ultrasound, indicating the presence of gas in the kidney. The gold standard is abdominal CT scan that reveals the presence of gas and obstruction in the urinary tract systems. Treatment should commence with fluid resuscitation, antibiotic therapy, and control of blood sugar and electrolytes. Percutaneous drainage or DJ-stenting is recommended in the patients with urinary tract obstruction. If the aforementioned measures fail, then emergency nephrectomy should be considered
Effectiveness of the Concurrent Intravenous Injection of Dexamethasone and Metoclopramide for Pain Management in Patients with Primary Headaches Presenting to Emergency Department
Get PDFIntroduction: Headache is a common reason for visiting emergency departments, and pain control is a major therapeutic goal in patients with headaches. Objective: The present study was conducted to examine the effectiveness of the concurrent intravenous administration of dexamethasone and metoclopramide in pain control in patients presenting to emergency departments with complaints of primary headache. Methods: This quasi-experimental study examined patients with moderate to severe headache attacks presenting to emergency departments. An 8-mg dose of dexamethasone and a 10-mg dose of metoclopramide were intravenously administered to the patients. The degree of headache was measured and recorded using the Numeric Rating Scale (NRS) upon admission and one hour and two hours after the injection. Results: A total of 51 patients with a mean age of 38.3±10.5 years participated in the study. The patients’ mean pain score was 8.4±1.3 upon admission and reduced to 6.2±2.3 one hour after the administration of the medication and to 3.1±2.9 two hours after the administration, suggesting significant reductions on both occasions (P<0.05). The therapeutic success was 39.2% one hour after the administration of the medication and 84.3% two hours after the administration. Conclusion: Based on these findings, the concurrent administration of dexamethasone and metoclopramide appears to affect the control of headache intensity in patients with primary headaches presenting to emergency departments
A Very General Overview of the Development Pediatric Emergency Medicine as a Specialty in the United States and Advocacy for Pediatric Healthcare; the Charge to Other Countries
Get PDFOne of the first noted instances regarding awareness of pediatric specific illnesses in the United States came from the writings of Dr. Benjamin Rush during the late 1700’s where he titled a section in his medical text “Diseases Specific to Children”. Throughout the 1700’s and 1800’s and even early 1900’s medicine was primarily a generalist profession where all ages were cared for by a personal family physician and there were virtually no subspecialties for adults or children. At that time in American history children were the great neglected segment of society in families, labor, and healthcare and were often treated more as property than valued life. There were a few pediatric advocates of note. Abraham Jacobi is considered the father of modern pediatrics and advocated for pediatrics being separated from the field of obstetrics. His actions were fundamental in the formation of the Section on Diseases of Children within the American Medical Association (AMA). In the 1930s there was a recognized need for separate pediatric specialty care advocacy organization and hence the development of the American Academy of Pediatrics (AAP) occurred. This was primarily born out of the lack of and need for federal funding to support pregnant women and children as well as the need for a foundational organization for the development of pediatrics as a specialty in the United States in the future. In the 1950’s pediatric poisonings became commonplace due to chemicals available after the end of World War II. As a result, the first poison control center was formed in Chicago and a manual was published by the AAP on pediatric poisonings. Similarly, the first cardiac surgeries for congenital heart disease were occurring and the specialty of pediatric cardiology was arising. The rising nuclear threat in the 1950’s and 1960’s also raised concern for disaster planning meeting specific pediatric needs and led to further committees, interest groups and publications. In addition, as trauma specialties and general emergency medicine grew under the auspices of the American College of Emergency Physicians (ACEP) and the American Heart Association (AHA) so did the need for sub-specialization for pediatric emergency medicine (PEM). In the early 1980s as an outgrowth of the ACEP and AAP, plans to cooperate and create the subspecialty of PEM began. The goal of the specialty was to train specialists, procure resources funding for research, and standardize training. The first subspecialty board for PEM was administered in 1992 and has continues to this date. Another outgrowth was federally funded agency called Emergency Medicine Services for Children (EMSC) whose goal was to find and fund resources, research, and training for PEM specialists, particularly prehospital providers. As late as 2001 the Institute of Medicine in their periodic report regarding United States healthcare noted that most emergency departments were still largely deficient regarding preparedness for pediatric emergencies. Since that time there has been intense emphasis on preparedness for pediatric emergencies and now the United States has innumerable academic and community hospitals with full pediatric preparedness. Similarly, with the modern explosion of medical information it is now virtually impossible for any physician to know all of one field. Most certainly no general emergency physician can possibly know everything regarding PEM thus obviating the need for PEM specialists to provide optimum care beyond the basics. Numerous studies in the United States have also demonstrated seriously ill or injured children care receive superior care with better outcomes when cared for in pediatric specific facilities. This does not imply that general emergency medicine and pediatric emergency medicine cannot co-exist and have economy of resources. It simply seems to be true that the best possible pediatric care is delivered by pediatric subspecialists with appropriate resources, funding, facilities and training.
As such it is now inconceivable that an appropriate healthcare system in the United States could exist without easily available pediatric specific resources such as PEM. Nonetheless, pediatrics continues to compete with adult specialties for resources as adults continue to have a conscious and unconscious bias toward them because of perceived greater adult patient productivity and contribution to society as a whole.
In conclusion, no matter what country, there will always be a need for committed individual and organizational advocates for the specific needs of children including the firm belief in pediatric subspecialties such as pediatric emergency medicine
Ultrasound-Guided Emergency Pericardiocentesis of a Patient with Multiple Myeloma in a Resource Limited Setting
Get PDFIntroduction: Cardiac tamponade, a variant of cardiogenic shock, is a medical emergency. A traumatic cardiac tamponade is an expected phenomenon; however, in non-traumatic events such as malignant pathology, it is usually less dramatic and takes several days or weeks to manifest. Occurrence of tamponade physiology due to pericardial effusion in a patient with multiple myeloma is a distinctly unusual entity. The involvement of a serous cavity in multiple myeloma is rare and pericardial effusion in such a case is due to restrictive cardiomyopathy or amyloidosis, a presentation late in the course of the disease that carries a grave prognosis. Case presentation: We present to you a case of a 60-year-old patient with cardiac tamponade due to pericardial effusion secondary to an advanced multiple myeloma. Due to the early diagnosis, she underwent a successful emergency pericardiocentesis with a central venous catheter under ultrasound guidance even in a resource limited emergency department (ED) of a district in southern India. She also showed marked improvement after the procedure and was transferred to the intensive care unit for further management. Conclusion: Cardiac tamponade is not an “all or none” phenomenon, but rather a continuum of findings. A high index of suspicion and timely clinical decision-making is the key for an emergency physician. Although there are several mimics for cardiac tamponade in ED, it is important for an emergency physician to be aware of such varied presentations of a disease spectrum owing to its rarity and clinical importance