Emergency management of critically ill adult patients with inherited metabolic disorders.

INTRODUCTION: An increasing number of pediatric patients with inherited metabolic disorders are reaching adulthood. In addition, many patients are diagnosed for the first time in adult life due to improved awareness of these disorders and the availability of advanced diagnostic technology. Knowledge of these inherited metabolic disorders in adults is crucial for the emergency physician to promptly recognize their acute illness and appropriately manage them in the emergency department. OBJECTIVE: This review provides an overview of various inherited metabolic disorders which present to the emergency department with acute metabolic decompensation. EVALUATION AND MANAGEMENT: Acute illness in these patients is often triggered by a catabolic event such as intercurrent illness, fasting, postpartum, or use of certain medication. It may present in a variety of ways related to severe hyperammonemia, metabolic acidosis, leucine encephalopathy or hypoglycemia. In this review, we describe the clinical presentation, evaluation and immediate management of their critical illness in the emergency department. CONCLUSION: Acute metabolic decompensation is a life-threatening condition. The emergency physician is usually the first provider to evaluate these patients when they present to the emergency department. Early recognition of their illness and prompt management of these cases improve patient outcomes.

Acute ST-Segment Elevation Myocardial Infarction Following Intramuscular Diclofenac: A Case of Kounis Syndrome.

BACKGROUND: Kounis syndrome (allergic myocardial infarction) is the rare occurrence of systemic anaphylaxis with spontaneous electrocardiographic changes in response to an exogenous agent. Often the syndrome is caused by a drug reaction involving drugs such as non-steroidal anti-inflammatory drugs, antibiotics, or opioids. There are a few reported cases in the literature regarding diclofenac-induced Kounis syndrome, and little is known about the management of this clinical entity. CASE REPORT: A case of Kounis syndrome with ST-elevation myocardial infarction secondary to intramuscular (i.m.) diclofenac in a patient with prior coronary artery bypass graft surgery is described in this report. Additionally, we discuss the pathophysiology, clinical presentation, and management of this rare clinical entity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As i.m. diclofenac is a commonly used drug in the emergency department, we urge emergency physicians to be aware of the existence of this potentially fatal diclofenac-related adverse drug effect. If Kounis syndrome is suspected, the emergency physician is advised to balance the benefit of epinephrine for the treatment of anaphylaxis with the small theoretical risk of increasing coronary vasospasm.

Venous thromboembolism prophylaxis and the impact of a thrombosis service at a Canadian level 1 trauma centre

Background: Venous thromboembolism (VTE) is a common and serious complication seen in patients with trauma. Guidelines recommend the routine use of pharmacologic prophylaxis; however, compliance rates vary widely. The aim of this study was to describe the clinical practice related to VTE prophylaxis in the first 24 hours after injury at our level 1 Canadian trauma centre and the impact of a thrombosis consultation service. Methods: We performed a retrospective review of the health records of adult patients with trauma admitted between Jan. 1, 2012, and June 30, 2013. The rate of VTE was ascertained. The use of an initial prophylactic regimen, potential contraindications to prophylaxis and involvement of the thrombosis service were determined. Results: A total of 633 patients were included, 459 men and 174 women with a mean age of 47.4 years. The mean Injury Severity Score was 15.8. The overall VTE rate was 2.8%. A total of 514 patients (81.2%) received VTE prophylaxis, mechanical in 302 (47.7%) and pharmacologic in 231 (36.5%) (19 patients received both types). The thrombosis service was involved in the care of 164 patients (25.9%). Patients seen by the thrombosis service were more likely to receive VTE prophylaxis than those not seen by the service (145 [88.4%] v. 369 [78.7%], p < 0.01). Conclusion: Compliance with VTE prophylaxis administration was suboptimal, and opportunities for improvement exist. The involvement of a thrombosis consultation service appears to improve compliance with VTE prophylaxis, and augmented use of this service may improve clinical outcomes.

Contexte: La thromboembolie veineuse (TEV) est une complication grave et fréquente chez les patients vus en traumatologie. Les lignes directrices recommandent l'utilisation systématique d'une prophylaxie pharmacologique; par contre, les taux de conformité aux lignes directrices varient beaucoup. Le but de cette étude était de décrire la pratique clinique en matière de thromboprophylaxie dans notre centre de traumatologie canadien de niveau 1 au cours des 24 premières heures suivant un traumatisme et l'impact d'un service de prévention des thromboses. Méthodes: Nous avons procédé à une revue rétrospective des dossiers médicaux de patients adultes hospitalisés en traumatologie entre le 1er janvier 2012 et le 30 juin 2013. Le taux de TEV a été mesuré et nous avons vérifié si un schéma prophylactique initial avait été utilisé, s'il y avait des contre-indications potentielles à la prophylaxie et si le service de prévention des thromboses avait été mis à contribution. Résultats: En tout, 633 patients ont été inclus, 459 hommes et 174 femmes âgés en moyenne de 47,4 ans. L'indice moyen de gravité de la blessure (IGB) était de 15,8. Le taux global de TEV a été de 2,8 %. En tout 514 patients (81,2 %) ont reçu une thromboprophylaxie (mécanique chez 302 [47,7 %] et pharmacologique chez 231 [36,5 %]; 19 patients ont reçu les 2 types de prophylaxie). Le service de prévention des thromboses a été impliqué dans 164 dossiers (25,9 %). Les patients vus par le service de prévention des thromboses étaient plus susceptibles que les autres patients de recevoir une thromboprophylaxie (145 [88,4 %] c. 369 [78,7 %], p < 0,01). Conclusion: La conformité aux lignes directrices sur la thromboprophylaxie a été sous-optimale, et il est possible de l'améliorer. L'implication d'un service de prévention des thromboses semble améliorer la conformité aux lignes directrices sur la thromboprophylaxie et y faire appel plus souvent pourrait améliorer les résultats cliniques.

Tobacco hookah smoking-induced carbon monoxide poisoning: A case report of non-ambient exposure.

Carbon monoxide (CO) toxicity should be considered in patients presenting to the emergency department with any acute vague manifestations after hookah smoking; furthermore, smoking in an open space does not eliminate the risk of CO toxicity. High-flow supplemental oxygen should be provided immediately while further investigations and management options are considered.

Spontaneous Pneumomediastinum in a Healthy Young Male: A Case Report from Riyadh, Saudi Arabia.

Pneumomediastinum is defined as the presence of air in the mediastinum. Trauma to the nearby organs can cause air to escape into surrounding tissues that may manifest clinically as severe chest pain, voice change, or shortness of breath. However, pneumomediastinum can present spontaneously in healthy individuals with no inciting factors in which case the condition is termed spontaneous pneumomediastinum (SPM). Pneumomediastinum can be challenging to manage due to the absence of clear guidelines for the diagnosis and management. We present the case of a 21-year-old with no previous medical history who presented with chest pain that was aggravated by speech and breath. The pain was of sudden onset preceded by smoking at 2:00 am. The patient was tachycardic, tachypnoeic with crepitation on palpation and a crunch sound (Hamman's sign) on auscultation. The patient rated the pain as 5/10 on a 11-point numerical pain rating scale, which then evolved to 10/10. The patient did not have fever, loss of consciousness (LOC), diaphoresis, history of trauma, or previous similar presentation. There were no other associated symptoms. A chest X-ray (posteroanterior (PA) and lateral view) showed pneumomediastinum, but laboratory tests results were otherwise normal. The patient was observed in the emergency room overnight. He remained stable, his tachycardia settled, and there was no leukocytosis or desaturation; however, tachypnea was observed. His pain symptoms were treated with analgesia as needed and the patient was discharged home in a stable condition, to be followed on an outpatient basis. Spontaneous pneumomediastinum can be challenging to manage due to the lack of reliable incidence data as well as the absence of clear management guidelines. Further research will aid in understanding the true incidence of SPM in Saudi Arabia and help in establishing a consensual approach and treatment guidelines to deal with SPM in otherwise healthy individuals. To the best of our knowledge, this is the first case of SPM in a young male reported from a tertiary hospital in Riyadh, Saudi Arabia.