Hemodynamic effects of nitroglycerin ointment in emergency department patients.

BACKGROUND: Nitroglycerin ointment is commonly used in the treatment of emergency department (ED) patients with suspected acute heart failure (AHF) or suspected acute coronary syndrome (ACS), but its hemodynamic effects in this population are not well described. OBJECTIVE: Our objective was to assess the effect of nitroglycerin ointment on mean arterial pressure (MAP) and systemic vascular resistance (SVR) in ED patients receiving nitroglycerin. We hypothesized that nitroglycerin ointment would result in a reduction of MAP and SVR in the acute treatment of patients. METHODS: We conducted a prospective, observational pilot study in a convenience sample of adult patients from a single ED who were treated with nitroglycerin ointment. Impedance cardiography was used to measure MAP, SVR, cardiac output (CO), stroke volume (SV), and thoracic fluid content (TFC) at baseline and at 30, 60, and 120 min after application of nitroglycerin ointment. Mixed effects regression models with random slope and random intercept were used to analyze changes in hemodynamic parameters from baseline to 30, 60, and 120 min after adjusting for age, sex, and final ED diagnosis of AHF. RESULTS: Sixty-four subjects with mean age of 55 years (interquartile range, 48-67 years) were enrolled; 59% were male. In the adjusted analysis, MAP and TFC decreased after application of nitroglycerin ointment (p=0.001 and p=0.043, respectively). Cardiac index, CO, SVR, and SV showed no change (p=0.113, p=0.085, p=0.570, and p=0.076, respectively) over time. CONCLUSIONS: Among ED patients who are treated with nitroglycerin ointment, MAP and TFC decrease over time. However, other hemodynamic parameters do not change after application of nitroglycerin ointment in these patients.

Necrotizing fasciitis of the paraspinous muscles.

Necrotizing fasciitis (NF) is a rare and lethal soft tissue infection that requires urgent surgical intervention. It is most often found in the extremities occurring with precipitating trauma or in immunocompromised states. Signs and symptoms are often vague or missing making early diagnosis very difficult. Our patient presented with flank pain and altered mental status but no known precipitating factors. Computed Tomography showed gas within and around the right paraspinous muscle suspicious for NF. Given NF's high lethality, early suspicion by emergency physicians of NF in patients with soft tissue infections or with systemic findings of unknown etiology is necessary.

A Case of Complicated Urinary Tract Infection: Klebsiella pneumoniae Emphysematous Cystitis Presenting as Abdominal Pain in the Emergency Department.

THIS CASE REPORT DESCRIBES AN ATYPICAL PRESENTATION OF AN ATYPICAL DISEASE ENTITY: Emphysematous Cystitis, a rapidly progressive, ascending urinary tract infection, in an emergency department (ED) patient whose chief complaint was abdominal pain and who had a urinalysis not consistent with the diagnosis of cystitis.