Recurrent Posterior Reversible Encephalopathy Syndrome in a Pediatric Patient With End-stage Renal Disease

Background

Posterior reversible encephalopathy syndrome (PRES) is a condition manifested by altered mental status, seizures, headaches, and visual loss. Specific abnormalities are seen by computed tomography or magnetic resonance imaging. Awareness of this syndrome is important for Emergency Physicians because visual loss can be reversible with prompt treatment of the underlying cause.

Objective

We present a case of recurrent PRES in a 14-year-old female who presented to the Emergency Department (ED) for headache and photosensitivity.

Case Report

A patient with a history of end-stage renal disease of unknown etiology was brought in by her mother for headache and photosensitivity. The patient developed blurry vision, seized in the ED, and required intubation. She was discharged 2 weeks later with complete return of vision. The same patient presented to the ED many times during the next several months for hypertensive emergencies, with three subsequent episodes that involved either seizures, vision loss, or both. Each of the episodes resolved with aggressive control of blood pressure in the pediatric intensive care unit.

Conclusions

PRES should be considered in all patients presenting to the ED with visual loss, seizures, or headache, and can be recurrent in some individuals. Prompt treatment can help prevent permanent vision loss.     

Tension Pneumocephalus: An Uncommon Cause of Altered Mental Status

Background

Pneumocephalus is a rare cause of altered mental status in patients presenting to the Emergency Department. Occurring as a result of traumatic or iatrogenic violation of the dura, it can cause significant morbidity and mortality if tension physiology develops whereby air continues to accumulate with no mechanism for escape.

Objective

This case report will review the underlying pathophysiology, clinical presentation, diagnosis, and management of tension pneumocephalus.

Case Report

We present the case of an 89-year-old man who presented to the Emergency Department with declining mental status 9 h after endoscopic sinus surgery. He was subsequently found to have tension pneumocephalus and underwent emergent burr hole evacuation. Despite resolution of the pneumocephalus, the patient had persistent neurologic deficits related to ischemic infarcts that occurred as a result of the tension physiology and subsequently expired in the hospital.

Conclusion

This case illustrates the importance of considering tension pneumocephalus on the differential diagnosis for any patient presenting with altered mental status after surgical or diagnostic procedures with potential to violate the dural space.     

Acute encephalopathy with concurrent respiratory and metabolic disturbances in first known parenteral human administration of flunixin meglumine and acepromazine maleate

Background

Flunexin is a nonsteroidal anti-inflammatory drug approved for veterinary use in horses and cattle. Acepromazine is a phenothiazine derivative used in horses, dogs, and cats. Human exposure to these substances is rare.

Case Report

We report a case of a human injection of two equine medications, flunixin and acepromazine, which resulted in altered mental status, respiratory alkalosis, gastrointestinal bleeding, and elevation of liver transaminases in a 43-year-old woman who worked as a horse trainer. The patient intentionally self-injected these medications and subsequently presented to the Emergency Department with altered mental status and lethargy. The patient required hospitalization for metabolic abnormalities, including respiratory alkalosis, and suffered a gastrointestinal bleed requiring blood transfusion. The patient ultimately recovered with supportive measures. We believe this to be the first case of concomitant injection of flunixin and acepromazine in a human.

Conclusions

This report explains a case of parenteral administration of two equine medications and the subsequent complications in a patient that presented to the Emergency Department. Human exposure to veterinary medications cannot be predicted by their effect in animals due to variations in absorption, distribution, and metabolism. Physicians should be aware that individuals who work with animals may have access to large quantities of veterinary medicine. This case also exemplifies the challenges that Emergency Physicians face on a daily basis, and generates additional consideration for overdoses and intoxications from medications that are not considered commonplace in humans.     

An Unusual Cause of Congestive Heart Failure in a Young Woman

Background

Congestive heart failure (CHF) is a common Emergency Department (ED) disorder that accounts for >5 million ED visits annually. Although quite rare, patent ductus arteriosus (PDA) is a serious cause of CHF that if left untreated can lead to life-threatening sequelae, such as hypertensive pulmonary vascular disease, endarteritis, and aneurysms of the ductus.

Objective

To discuss a case of PDA leading to CHF that illustrates one of the common complications of untreated PDA.

Case Report

A 35-year-old woman presented to the ED with a 2-month history of shortness of breath, dyspnea on exertion, decreased exercise tolerance, and orthopnea. The physical examination revealed a 4/6 continuous machine-like murmur. In the presence of new CHF and an atypical murmur, a transthoracic echocardiogram was performed that confirmed the diagnosis of PDA. She underwent an uncomplicated percutaneous closure of the ductus with significant improvement in her symptoms.

Conclusions

Persistent PDA in adulthood is a rare but important cause of CHF with significant morbidity and mortality if not appropriately diagnosed and treated.     

Hypotension after medical termination of pregnancy: think outside of the uterus

Background

Under usual circumstances, an ectopic pregnancy would not be generally considered in the initial differential diagnosis of shock after voluntary termination of pregnancy.

Objective

To present a rare case of a young woman with shock after voluntary termination of pregnancy due to undiagnosed ectopic pregnancy with concealed hemorrhage.

Case Report

A 37-year-old woman presented to the Emergency Department (ED) 3 days after termination of pregnancy with clinical features of shock. The patient had some evidence of infection and was initially managed as a case of septic shock secondary to possible complication of recent termination of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and ruptured ectopic pregnancy was confirmed and managed successfully.

Conclusion

Ruptured ectopic pregnancy can present with a wide range of symptoms and under variable circumstances. Recognition of subtle signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in the ED will lead to early diagnosis and appropriate management.     

Intraosseous Administration of Thrombolytics for Pulmonary Embolism

Background

Massive pulmonary embolism is associated with cardiac dysfunction and ischemia, hemodynamic collapse, and significant potential for death. The American College of Chest Physicians and American College of Emergency Physicians each supports thrombolytic administration to hemodynamically unstable patients with acute pulmonary embolism.

Objectives

In the resuscitation of patients with massive pulmonary embolism and obstructive shock, difficulty with vascular access can hinder care. Alternative options may facilitate delivery of thrombolytics and enhance patient management.

Case Report

The case presented is a 36-year-old woman with massive pulmonary embolism associated with hemodynamic instability. She was treated with thrombolytics through a tibial intraosseous line.

Conclusions

To the best of our knowledge, this is the first identified case of a patient not in cardiac arrest in whom thrombolytics were administered via an intraosseous line. Similarly, we believe this is also the first reported case of thrombolytics delivered via an intraosseous line for massive pulmonary embolism in the United States.     

Acute Vision Loss: A Fuzzy Presentation of Sarcoidosis

Background

Acute vision loss is a devastating problem for patients and a challenging diagnostic dilemma for Emergency Physicians. This chief complaint is one in which we must be adept at quickly evaluating and initiating either care or referral.

Objectives

This case reviews the approach to acute vision loss and shows the importance of expanding the differential in atypical and complex presentations.

Case Report

A 31-year-old, previously healthy, white woman presented to the Emergency Department (ED) with 1 day of painless right eye vision loss. Ocular ultrasound and slit-lamp examination were unremarkable. Fundoscopic examination revealed retinal hemorrhages and papillitis. Her chest X-ray study was significant for bilateral hilar adenopathy, and subsequent lymph node biopsy confirmed the diagnosis of sarcoidosis.

Conclusions

Although sarcoidosis is more common in African Americans, it must be considered in all patients in the appropriate clinical context. Sarcoidosis is an important diagnosis to include on the differential of many chief complaints that present to the ED, including acute vision loss and dyspnea.     

Hepatic Artery Pseudoaneurysm Rupture: A Case Report and Review of the Literature

Background

Ruptured hepatic artery pseudoaneurysm, a type of visceral artery aneurysm, is a rare condition that is life threatening if not diagnosed and treated rapidly in the emergency department (ED). Patients presenting with this condition require aggressive resuscitation. Endovascular embolization is the first-line treatment option.

Objectives

We present a case of spontaneously ruptured hepatic artery pseudoaneurysm and provide a review of the current literature on this topic, focusing on appropriate ED management.

Case Report

A 41-year-old woman with a history of systemic lupus erythematosus and multiple hepatic bilomas presented to the ED in critical condition with sudden onset of severe abdominal pain and hemodynamic instability. She was found to have a ruptured hepatic artery pseudoaneurysm with marked hemoperitoneum on computed tomography angiography. She was aggressively resuscitated and successfully managed via endovascular embolization.

Conclusion

Ruptured hepatic artery pseudoaneurysm is a life-threatening condition that must be rapidly diagnosed and managed in the ED. Visceral artery aneurysm rupture is a diagnosis that should be considered in any patient presenting to the ED with hemodynamic instability and abdominal pain. Definitive management is with endovascular embolization.     

Near-Miss in Focused Lower-Extremity Ultrasound for Deep Venous Thrombosis

Background

Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS.

Objective

A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis.

Case Report

We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis.

Conclusion

Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.     

Patient Satisfaction in the Emergency Department and the Use of Business Cards by Physicians

Background

Emergency departments (EDs) across the country become increasingly crowded. Methods to improve patient satisfaction are becoming increasingly important.

Objective

To determine if the use of business cards by emergency physicians improves patient satisfaction.

Methods

A prospective, convenience sample of ED patients were surveyed in a tertiary care, suburban teaching hospital. Inclusion criteria were limited to an understanding of written and spoken English. Excluded patients included those with altered mental status or too ill to complete a survey. Patients were assigned to receive a business card on alternate days in the ED from the treating physician(s) during their patient introductions. The business cards listed the physician’s name and position (resident or attending physician) and the institution name and phone number. Before hospital admission or discharge, a research assistant asked patients to complete a questionnaire regarding their ED visit to determine patient satisfaction.

Results

Three hundred-twenty patients were approached to complete the questionnaire and 259 patients (81%) completed it. Patient demographics were similar in both the business card and non-business-card groups. There were no statistically significant differences for patient responses to any of the study questions whether or not they received a business card during the physician introduction.

Conclusion

The use of business cards during physician introduction in the ED does not improve patient satisfaction.     

ED administration of thienopyridines in non–ST-segment elevation myocardial infarction: results from the NCDR

Objective

American Heart Association/American College of Cardiology guidelines recommend that patients with definite unstable angina or non–ST-segment elevation myocardial infarction (NSTEMI) receive dual antiplatelet therapy on presentation to the hospital when undergoing early invasive management or “as soon as possible” after admission when being managed conservatively. The guidelines do not specify whether these medications should be administered in the emergency department (ED). Our aim was to determine whether ED administration of a thienopyridine was associated with clinical outcomes among patients with NSTEMI.

Methods

We examined thienopyridine use in 39 454 patients with NSTEMI who received a thienopyridine within 24 hours of presentation in the National Cardiovascular Data Registry's Acute Coronary Treatment and Intervention Outcomes Network–Get With The Guidelines Registry from January 2007 to June 2010. Patients who were not seen initially in the ED, were transferred in, or were missing time data were excluded. We analyzed the association between ED administration of thienopyridines and outcomes and patient demographics.

Results

Of the cohort receiving a thienopyridine within 24 hours, 9534 (24.2%) received it in the ED. Emergency department administration of a thienopyridine was not associated with in-hospital major bleeding (multivariable adjusted odds ratio, 0.99; 95% confidence interval, 0.91-1.09) or in-hospital mortality (adjusted 1.02; 95% confidence interval, 0.86-1.20). Independent predictors most strongly associated with ED thienopyridine administration were elevated troponin, ED length of stay, prior percutaneous coronary intervention, and initial electrocardiogram showing ischemic changes.

Conclusions

There was no association between ED thienopyridine administration and in-hospital major bleeding or mortality. Emergency department length of stay, electrocardiographic changes, and elevated troponin were associated with ED thienopyridine administration.     

Black urine due to urobilinogen in a patient with alcoholic pellagra

Objectives

Systemic exposure to drugs, chemicals and foods can cause abnormally colored urine. Food exposures are typically benign, but urine discoloration due to chemicals or drugs may indicate a potentially dangerous condition. Discolored urine can also be caused by medical problems. This brief report reviews the laboratory findings leading to lactic acidosis and elevated urine urobilinogen in an alcoholic patient with pellagra.

Design and methods

A 66-year-old male, found unconscious in his hotel room, was brought to the emergency department (ED). Upon arrival he had hypothermia, a diffuse rash and altered mental status. During ED evaluation, a urinary catheter was placed and demonstrated black urine. Medical history noted chronic alcoholism, malnutrition, and poor self-care.

Results

Evaluation in the hospital suggested that his rash and neurologic changes were a result of malnutrition and vitamin deficiency. A thorough biochemical workup demonstrated that elevated urobilinogen was likely causing the patient's black urine. Serum niacin concentration was undetectable. His dermatitis improved with multivitamins, thiamine, and niacin as well as topical steroids. His mental status returned to baseline and he was discharged to a skilled nursing facility following a brief hospital stay.

Conclusions

The patient's abnormal laboratory results were explained by his alcoholism and poor nutrition. Furthermore, urine color returned to normal with decreased concentration of urobilinogen, after vitamin supplementation and supportive medical care.     

Restraint Use in the Elderly Emergency Department Patient

Background

The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED).

Objective

This study examined outcomes of restrained elderly patients in the ED.

Methods

A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition.

Results

There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone.

Conclusion

In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.     

A Case of Spontaneous Pneumomediastinum and Epidural Pneumatosis in a Young Woman in the Emergency Department

Background

Pneumomediastinum is a relatively rare, yet typically benign, clinical condition that usually presents in young men.

Objective

This report will describe a relatively rare event of pneumomediastinum with epidural extension in a young woman and will discuss the etiology, clinical manifestations, and treatment options for this condition.

Case Report

The patient presented to the Emergency Department (ED) with typical symptoms of shortness of breath and chest pain, but was found on computed tomography to have epidural pneumatosis. No precipitating event was found.

Conclusion

This case of spontaneous pneumomediastinum with associated epidural pneumatosis in a young woman presenting to the ED is a relatively benign condition that typically does not require any significant work-up or treatment.     

Masked Hypoglycemia in the Presence of Icodextrin for Peritoneal Dialysis

Background

Handheld glucose meters remain a rapid means of excluding hypoglycemia as a cause of altered mental status in the Emergency Department. However, emergency physicians must be alert for factors that can mask hypoglycemia at the bedside.

Case Report

An 80-year-old man with diabetes mellitus and end-stage renal disease on peritoneal dialysis presents with altered mental status, hypotension, and a bedside handheld glucose meter reading of 99 mg/dL. His mental status failed to improve with treatment of hypotension and the patient was intubated for airway protection. Laboratory-measured serum glucose was 29 mg/dL. His mental status improved after glucose administration. It was subsequently determined that the patient used icodextrin (Extraneal^®, Baxter Healthcare Corporation, Deerfield, IL) as his peritoneal dialysate. This is partly absorbed into serum and hydrolyzed to oligosaccharides that are falsely detected as glucose by many handheld glucose meters.

Conclusion

The peritoneal dialysate icodextrin can produce falsely elevated bedside glucose meter values. As the prevalence of diabetic nephropathy and dialysis increases, emergency physicians must remain vigilant for such cases of unrecognized hypoglycemia.     

A Case of Foreign Accent Syndrome

Background

Foreign accent syndrome is a rare but potentially devastating clinical condition associated with altered speech rhythm and prosody, often occurring after a cerebral vascular accident. Missing this diagnosis can lead to delayed stroke work-up and treatment.

Objective

We report a case of foreign accent syndrome in a 60-year-old woman who presented to the Emergency Department (ED) with 3 weeks of altered speech pattern, widened gait, bilateral leg heaviness, and mild headache.

Case Report

The patient had a history of Type 2 diabetes, malignant hypertension, toxic nodular goiter, and hyperlipidemia. She initially presented to the ED at the onset of symptoms, was thought to have had speech change secondary to a goiter impinging on the recurrent laryngeal nerve, and was discharged. She returned to the ED 3 weeks later when outpatient imaging revealed subacute infarction of the left hemi-pons and absent flow within the left vertebral artery. On examination, the patient was alert and conversational. She spoke fluently with an accent that had components of Jamaican and the accent of an Italian speaking English. Neurology was consulted and the patient was admitted. The patient was treated medically, and was discharged home with primary care follow-up. She developed a second, more significant stroke 1 month later, with unilateral weakness and slurred speech in the middle cerebral artery distribution.

Conclusion

Clinicians should be aware that some stroke patients present with various atypical symptoms, and should suspect stroke in any patient with acute-onset neurological symptoms, including speech change.     

Vitamin deficiencies in acutely intoxicated patients in the ED

Objective

Physicians often administer intravenous multivitamins to intoxicated patients in the emergency department (ED); however, this practice is not supported by evidence from any prior study. We determined the prevalences of vitamin deficiencies in patients presenting to our ED with alcohol intoxication.

Methods

This study was a prospective, cross-section, observational study of a convenience sample of ED patients presenting with acute alcohol intoxication. Patients were tested for B₁₂, folate, and thiamine levels as add-ons to their blood samples.

Results

Seventy-seven patients were included in the final analysis. The mean age was 46 years, and 19% were female; the mean blood alcohol level was 280 mg/dL. Of 75 patients, no one (0%) had low B₁₂ or folate levels (95% confidence interval, 0-0.05); 6 (15%) of 39 patients had low thiamine levels (95% confidence interval, 0.06-0.31). Of these 6 patients, none exhibited clinical signs of thiamine deficiency.

Conclusions

In our ED, patients with acute ethanol intoxication do not have B₁₂ or folate deficiencies. A significant minority (15%) of patients have thiamine deficiency; its clinical significance is unclear. Widespread administration of multivitamins is unwarranted by these findings, but thiamine may be considered.     

Outcomes in Canadian Emergency Department Syncope Patients – Are We Doing a Good Job?

Background

Little is known about the outcomes of adults with syncope seen in Canadian Emergency Departments (EDs).

Objectives

We sought to determine the frequency, timing, and type of serious adverse outcomes occurring in these patients, and the proportion that occur outside the hospital.

Methods

We conducted a health records review of syncope patients presenting to a tertiary care ED over an 18-month period. We included all patients older than 16 years of age who fulfilled the syncope definition (sudden transient loss of consciousness with spontaneous complete recovery), and excluded those with altered mental status, alcohol or illicit drug use, seizure, or trauma. We assessed for outcomes in the ED and after ED disposition. We also evaluated follow-up arrangements for patients discharged from the ED.

Results

Of the total 87,508 patient visits, 505 (0.6%) were due to syncope. The mean age was 58.5 years (range 16–101 years), 70.1% arrived by ambulance, and 12.3% were admitted to the hospital. Five patients died: 2 in the ED, 1 as an inpatient, and 2 after discharge. Overall, there were 49 (9.7%) serious outcomes, with dysrhythmias being the most common (4.6%); 22 (4.4%) occurred in the ED, 15 (3.0%) in the hospital, and 12 (2.4%) outside the hospital. Eight serious outcomes occurred in patients discharged from the ED without any planned follow-up.

Conclusion

Although syncope represented < 1% of all patient visits, morbidity was substantial, particularly in patients discharged from the ED. Future research should help clinicians identify syncope patients at high risk for serious outcomes.     

Acute Respiratory Failure during Routine Blood Transfusion: A Case Report and Review of the Literature

Background

Transfusion medicine is a common practice in the emergency department (ED) and other outpatient settings, and may be complicated by a low rate of potentially fatal transfusion-related reactions.

Objectives

This article presents a case of transfusion-related acute lung injury (TRALI) diagnosed and treated in the ED and reviews the differential diagnosis of acute transfusion reactions.

Case Report

A 74-year-old woman presented to the ED from the hospital's transfusion center with fever and respiratory distress immediately after the start of her second unit of red blood cell transfusion. Chest radiograph demonstrated a pattern consistent with acute respiratory distress syndrome (ARDS). After 48 h of respiratory support and antibiotic therapy, the patient's condition improved.

Conclusion

TRALI is a clinical diagnosis with presentation similar to that of ARDS. Prompt differentiation from other transfusion reactions and initiation of appropriate treatment is crucial in minimizing the morbidity and mortality associated with this syndrome.     

Don't get sick on the weekend: an evaluation of the weekend effect on mortality for patients visiting US EDs

Primary objective

The primary objective of the study is to determine if the mortality for adult patients visiting US emergency departments (EDs) is greater on weekends than weekdays.

Secondary objectives

The secondary objective of the study is to examine whether patient factors (diagnosis, income, insurance status) or hospital characteristics (ownership, ED volume, teaching status) are associated with increased weekend mortality.

Methods

We used a retrospective cohort analysis of the 2008 Nationwide Emergency Department Sample. Evaluating 4 225 973 adults admitted through the ED to the hospital, signifying a 20% representative sample of US ED admissions. Logistic regression was used to examine associations of weekend mortality with patient and hospital characteristics, accounting for clustering by hospital.

Results

Emergency department patients admitted to the hospital on the weekend are significantly more likely to die than those admitted on weekdays (odds ratio, 1.073; 95% confidence interval, 1.061-1.084). A significant weekend effect persisted after controlling for patient characteristics (odds ratio, 1.026; 95% confidence interval, 1.005-1.048). The top 10 primary diagnoses for patients dying did not identify any specific medical condition that explained the higher weekend admission mortality. The weekend effect was also relatively consistent across patient income, insurance status, hospital ownership, ED volume, and hospital teaching status.

Conclusion

Patients are more likely to die when admitted through the ED on the weekend. We were unable to identify specific circumstances or hospital attributes that help explain this phenomenon. Although the relative increased risk per case is small, our study demonstrates a significant number of potentially preventable weekend deaths occurring annually in the United States.