Internal Carotid Artery Occlusion as a Rare Presentation of Infectious Endocarditis: A Case Report.

INTRODUCTION: Internal carotid artery occlusion as a result of a septic embolism is a rare, commonly fatal, complication of mitral valve infectious endocarditis. Prompt recognition of this condition by the emergency physician may improve the chance of functional neurological survival. CASE REPORT: A 50-year-old male presented minimally responsive with a right gaze deviation, left hemiparesis, and a score of 26 on the National Institutes of Health Stroke Scale. A point-of-care echocardiogram showed a large mitral valve vegetation, and computed tomography angiography demonstrated an internal carotid artery occlusion. CONCLUSION: The emergency physician should consider this potentially life-threatening condition and know the fundamental management recommendations once identified.

Acute Pelvic Pain.

Acute pelvic pain has gynecologic and nongynecologic causes, and distinguishing between them can be difficult in the emergency department. Ovarian cysts, adnexal torsion, and pelvic inflammatory disease are conditions that emergency physicians must be able to identify. Pelvic pathologic condition can be readily assessed with ultrasound but has significant limitations. Adnexal torsion can occur despite normal vasculature on ultrasound with Doppler; patients with significant pain or risk factors may require exploratory laparotomy. Emergency physicians and clinicians must be prepared to manage all aspects of pelvic emergencies, both gynecologic and nongynecologic.

Prolonged QRS Widening After Aripiprazole Overdose.

BACKGROUND: Aripiprazole is an atypical antipsychotic with a long half-life. Overdose can result in protracted somnolence and cardiac disturbances, particularly QT interval prolongation. METHODS: This is a single case report of a 14-year-old boy who took an overdose of aripiprazole and developed QRS widening. CASE: A 14-year-old boy intentionally ingested 20 tablets of aripiprazole (5 mg). He was brought to the emergency department when his ingestion was discovered. The patient's vital signs were as follows: temperature, 37.7°C; heart rate, 108 beats/min; blood pressure, 138/98 mm Hg; and respirations, 16 breaths/min. Activated charcoal was administered within 90 minutes of ingestion. Initial electrocardiogram (EKG) showed sinus tachycardia, with a QRS of 138 ms and QT interval of 444 ms. QRS duration was 90 ms on an EKG performed 3 months earlier. A bolus of sodium bicarbonate was administered, and the patient was transferred to the pediatric intensive care unit. Repeat EKG demonstrated a QRS of 156 ms, and a sodium bicarbonate infusion was initiated. The patient continued to have QRS prolongation for the next 8 days, reaching a peak of 172 ms 3 days postingestion. Despite aggressive treatment with sodium bicarbonate, there was persistent QRS prolongation; however, the patient did not have any dysrhythmias and remained hemodynamically stable. The patient was discharged 9 days postingestion when the QRS duration normalized to 82 ms. Genetic testing revealed that the patient was a CYP2D6 poor metabolizer. CONCLUSIONS: This case suggests that aripiprazole toxicity may possibly be associated with QRS prolongation without associated dysrhythmias or cardiovascular compromise. In addition, toxicity may be prolonged in patients who are CYP2D6 poor metabolizers.

Trends in opioid analgesic use for headaches in US emergency departments.

OBJECTIVE: Although not recommended as first line therapy by consensus guidelines, opioid analgesics are commonly used to treat headaches. This study evaluates trends in opioid use for headaches in US emergency departments (EDs). METHODS: We performed a retrospective review of the National Hospital Ambulatory Medical Care Survey, 2001 through 2010. Adult headache-related visits were identified. Medications (opioid and nonopioid) used for the treatment of headache were categorized based on medication class. Trends in ED use of the most common opioids (codeine, hydrocodone, hydromorphone, morphine, and oxycodone) were explored. The proportion of visits for which each medication was used was tabulated, and trends were analyzed using survey-weighted logistic regression. RESULTS: Headache visits during which any opioid was used increased between 2001 (20.6%; 95% confidence interval [CI], 18.1-23.4) and 2010 (35.0%; 95% CI, 31.8-38.4; P < .001). Prescribing of hydromorphone, morphine, and oxycodone increased, with the largest relative increase (461.1%) in hydromorphone (2001, 1.8% [95% CI, 1.2-2.6]; 2010, 10.1% [95% CI, 8.2-12.4]). Codeine use declined, and hydrocodone use remained stable. Use of opioid alternatives, including acetaminophen, butalbital, and triptans did not change over the study period, whereas use of nonsteroidal anti-inflammatory drugs increased from 26.2% (95% CI, 23.0-29.7) to 31.4% (95% CI, 28.6-34.3). Prescribing of antiemetic agents decreased from 24.1% (95% CI, 19.6-29.2) to 23.5% (95% CI, 21.1-26.0). Intravenous fluid use increased from 20.0% (95% CI, 17.0-23.4) to 34.5% (95% CI, 31.0-38.2) of visits. CONCLUSIONS: Despite limited endorsement by consensus guidelines, there was increased use of opioid analgesics to treat headaches in US EDs over the past decade.