Elevated lipase without pancreatitis in infectious colitis.

BACKGROUND: An elevated lipase typically confirms the diagnosis of pancreatitis. Elevated lipase may be associated with other disorders, typically with some influence on the pancreas. The differential is more limited than elevated amylase secondary to the mostly unique production of lipase in pancreatic acinar cells. Elevated lipase has been reported in patients with inflammatory bowel disease, but not previously reported in infectious colitis. CASE REPORT: A 65-year-old woman presented to the emergency department with left lower quadrant abdominal pain radiating to her left flank worsening over 2 days. She denied epigastric pain. She had occasional nausea and occasional nonbilious and nonbloody emesis, and also reported diarrhea and weight loss over the preceding months. Laboratory values were largely unremarkable except for a grossly elevated lipase level. Computed tomography scan of her abdomen was performed and revealed findings consistent with infectious colitis, without signs of pancreatic inflammation or other findings associated with pancreatitis. She was admitted to the hospital and treated for infectious colitis with antibiotics and improved over 2 days, and was subsequently discharged for follow-up with her gastroenterologist. This is the first reported case of elevated lipase without pancreatitis associated with infectious colitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware of other potential causes of elevated lipase and not assume that all cases of elevated lipase are associated with pancreatitis. This may possibly avoid unnecessary admission in situations that are not clearly pancreatitis.

Asymmetric Weakness and West Nile Virus Infection.

BACKGROUND: Weakness is a common presentation in the emergency department (ED). Asymmetric weakness or weakness that appears not to follow an anatomical pattern is a less common occurrence. Acute flaccid paralysis with no signs of meningoencephalitis is one of the more uncommon presentations of West Nile virus (WNV). Patient may complain of an acute onset of severe weakness, or even paralysis, in one or multiple limbs with no sensory deficits. This weakness is caused by injury to the anterior horn cells of the spinal cord. We present a case of acute asymmetric flaccid paralysis with preserved sensory responses that was eventually diagnosed as neuroinvasive WNV infection. CASE REPORT: A 31-year-old male with no medical history presented with complaints of left lower and right upper extremity weakness. Computed tomography scan was negative and multiple other studies were performed in the ED. Eventually, he was admitted to the hospital and was found to have decreased motor amplitudes, severely reduced motor neuron recruitment, and denervation on electrodiagnostic study. Cerebrospinal fluid specimen tested positive for WNV immunoglobulin (Ig) G and IgM antibodies. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute asymmetric flaccid paralysis with no signs of viremia or meningoencephalitis is an unusual presentation of WNV infection. WNV should be included in the differential for patients with asymmetric weakness, especially in the summer months in areas with large mosquito populations.

Acute Pancreatitis: What's the Score?

BACKGROUND: Acute pancreatitis (AP) is a common presentation in the emergency department (ED). Severity of pancreatitis is an important consideration for ED clinicians making admission judgments. Validated scoring systems can be a helpful tool in this process. OBJECTIVE: The aim of this review is to give a general outline on the subject of AP and compare different criteria used to predict severity of disease for use in the ED. DISCUSSION: This review updates the classifications and scoring systems for AP and the relevant parameters of each. This article assesses past and current scoring systems for AP, including Ranson criteria, Glasgow criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II), computed tomography imaging scoring systems, Bedside Index of Severity in Acute Pancreatitis (BISAP) score, Panc 3, Harmless Acute Pancreatitis Score (HAPS), and the Japanese Severity Score. This article also describes the potential use of single variable predictors. Finally, this article discusses risk factors for early readmission, an outcome pertinent to emergency physicians. These parameters may be used to risk-stratify patients presenting to the ED into mild, moderate, and severe pancreatitis for determination of appropriate disposition. CONCLUSION: Rapid, reliable, and validated means of predicting patient outcome from rapid clinical assessment are of value to the emergency physician. Scoring systems such as BISAP, HAPS, and single-variable predictors may assist in decision-making due to their simplicity of use and applicability within the first 24 h.

Hyperkalemia and Electrocardiogram Manifestations in End-Stage Renal Disease.

Hyperkalemia is one of the more common acute life-threatening metabolic emergencies. The aim of our study is to determine the correlation and accuracy of abnormal ECG parameters as a function of serum potassium concentration in the end-stage renal disease (ESRD) population. We performed a retrospective chart review of emergency department patients presenting with ESRD and receiving emergent hemodialysis treatment. A total of 96 patients, each with five independent ED visits, provided 480 sets of ECGs and electrolytes. Of these, four ECGs were excluded for inability to interpret, leaving a total of 476 patient encounters that met all inclusion criteria. Linear regression analysis on the limited data set for serum potassium versus T/R in V2, V3, and V4, PR, and QRS found weak correlations (r2 = 0.02 to 0.12) with statistical significance <0.05 level for T/R in V2, V3, and V4. In summary, we found that a QRS duration of 120 ms or greater is most predictive of hyperkalemia in the ESRD population. On the other hand, T/R ratio, PR interval and QRS duration have poor correlations with serum potassium and are not predictive of hyperkalemia in patients with ESRD.

Emergency physician ability to predict methicillin-resistant Staphylococcus aureus skin and soft tissue infections.

Methicillin-resistant Staphylococcus aureus (MRSA) has a high prevalence in Emergency Departments (EDs). The objective of this study was to determine the ability of emergency physicians to predict MRSA infection in purulent wounds. A prospective observational study was conducted in an urban, tertiary academic center in ED patients presenting with purulent wounds and abscesses that received wound culture. Physicians completed a questionnaire with patient demographic data and their own suspicion for MRSA infection in eligible patients. For emergency physician ability to predict positive culture for MRSA, sensitivities, specificities, and positive and negative likelihood ratios (LRs) were calculated. Risk factors were assessed for statistical significance using a chi-squared test with p < 0.05. There were 176 patients enrolled, and 19 were eliminated for incomplete data. Physician suspicion of MRSA had a sensitivity of 80% (95% confidence interval [CI] 71%-87%) and a specificity of 23.6% (95% CI 14%-37%) for the presence of MRSA on wound culture with a positive LR of 1.0 (95% CI 0.9-1.3) and a negative LR of 0.8 (95% CI 0.5-1.3). Prevalence was 64%. Only intravenous drug use was significantly associated with MRSA. Emergency physician's suspicion of MRSA infection is a poor predictor of MRSA infection.

Brain natriuretic peptide (BNP) testing in the emergency department.

In the past decade a large amount of attention has been focused on brain natriuretic peptide (BNP) testing in the evaluation of patients with acute dyspnea as well as the screening of patients for congestive heart failure (CHF). Because BNP is secreted by myocytes in response to ventricular stretch, it has long been thought that BNP could become a biochemical marker for CHF. Rapid assays have been developed and BNP testing has been studied in detection of CHF and predictive outcomes in a large variety of settings. We review the clinical evidence associated with the use of BNP testing in the acute care setting. We conclude with a discussion of clinical utility in the emergency department for the evaluation of patients presenting with acute dyspnea.

Diagnosing and managing acute heart failure in the emergency department.

Heart failure is a clinical syndrome that results from the impairment of ventricular filling or ejection of blood and affects millions of people worldwide. Diagnosis may not be straightforward and at times may be difficult in an undifferentiated patient. However, rapid evaluation and diagnosis is important for the optimal management of acute heart failure. We review the many aspects of diagnosing and treating acute heart failure in the emergency department.

Depression and the Suicidal Patient.

Depression is the most common psychiatric illness in the general community, with 3% to 4% of depressives dying by suicide today. Studies have shown that depression has considerable morbidity and mortality. This article focuses on depressed patients and their management within the emergency department. Understanding the intricacies of the interview process and identifying which patients need immediate attention are important skills for the emergency physician.

Special Considerations in Trauma Patients.

The emergent management of a traumatic injury can be an extremely intense situation. These assessments can be even more difficult when patients have an underlying psychiatric condition. After a protocoled evaluation of the traumatic injuries, the psychological manifestation of diseases can be addressed. The appropriate use of physical or chemical restraints to facilitate the work-up is paramount in the ability of the provider to protect patients and staff from agitated and traumatized patients. The emergency medicine provider should have a low threshold for including psychiatry in the treatment plans, as the long-term sequelae of these entities require specialized treatment.

Environmental insults: smoke inhalation, submersion, diving, and high altitude.

In the expanding search for recreation, we spend more and more of our time in various environments. Whether the air is thin or compressed or smoke-filled or there is no air at all, emergency physicians continue to meet and treat the various pulmonary emergencies that the environment may create. The authors present the background, diagnosis, and management of a few of the more common pulmonary emergencies that the environment may produce.

Disorders of sodium and water balance.

Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.