Lingual Abscess in the Setting of Recent Periodontal Antibiotic Injections.

BACKGROUND: Lingual abscess is a rare clinical entity, with posterior involvement being much less common than anterior involvement. Typical inciting events include trauma or direct inoculation to the area. The clinical diagnosis can be difficult, and early imaging and specialist consultation should be pursued to make a definitive diagnosis and to prevent patient deterioration. CASE REPORT: We present a case of posterior lingual abscess in a 62-year-old man after he received antibiotic injections to the lower molars for periodontal disease. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Lingual abscess is a rare condition that is difficult to diagnose clinically. Misdiagnosis or delayed diagnosis can lead to acute airway compromise and increased morbidity.

Creatine kinase BB isoenzyme blood levels in trauma patients with suspected mild traumatic brain injury.

This pilot study sought to determine if creatine kinase isoenzyme BB (CK-BB) levels might serve as a biological marker of injury severity in mild TBI (mTBI). This was a retrospective study of 64 soldiers with suspected mTBI seen in a combat support hospital in Mosul between March and August of 2007. Four of the 64 total samples were positive for CK-BB. One major trauma patient had a negative CK-BB. This yields a sensitivity of 11% and a specificity of 97%. Military Acute Concussion Evaluation (MACE) scores collected also did not appear to reflect extent of injury. Although the low sensitivity of CK-BB from this study does not support its use as an early marker of suspected mTBI, the result is not conclusive given the small sample and the possibility of isoenzyme degradation during transport. Although limited, the data collected on MACE scores warrant additional evaluation of whether this measure is clinically relevant.

The effects of an accelerated triage and treatment protocol on left without being seen rates and wait times of urgent patients at a military emergency department.

To combat increasing wait times and left without being seen (LWOBS) rates, our emergency department (ED) implemented an accelerated triage and treatment (TNT) protocol. A TNT team was allocated treatment rooms to begin management of urgent patients if a bed in the main ED was not available. A retrospective database study was performed using three separate 6-month periods: two control periods before the intervention (P1, P2) and one period after the intervention (P3). The primary outcome measures were LWOBS rate, time to evaluation, and total ED time for urgent patients. The time to be seen for EC3 patients improved from P1 to P3 by an average of 12.6 minutes (18.5%, p < 0.0001) and from P2 to P3 by an average of 12.0 minutes (17.6%, p < 0.0001). The EC3 LWOBS rate decreased from 2.0% in P1 and 1.9% in P2 to 0.8% in P3 (p < 0.0001 for both). The use of an accelerated TNT protocol was associated with a significant reduction in EC3 patient LWOBS rates and time to evaluation.

Clinical course and toxicokinetic data following isolated citalopram overdose in an infant.

OBJECTIVE: Despite the frequency of use of citalopram, its clinical effects and pharmacokinetics in overdose in the pediatric patient are not well described. We describe the clinical course and drug levels following the ingestion of citalopram by a 10-month-old female. CASE REPORT: A 10 month-old female ingested an unknown amount of citalopram. Approximately 40 min after ingestion, the child developed horizontal nystagmus, followed by a generalized, tonic-clonic seizure that lasted 2 to 3 min very shortly thereafter. The child received 1 mg of midazolam intramuscularly (IM), followed by 1 mg of midazolam intravenously (IV) for termination of this seizure, and was given a loading dose of 20 mg/kg of fosphenytoin IV. Elective orotracheal intubation was done to protect the airway. Despite the use of midazolam and fosphenytoin, the child had another seizure approximately 85 min following the ingestion. A third seizure was noted at approximately 100 min post-ingestion. In the course of treatment, activated charcoal was administered via nasogastric tube, and IV midazolam and phenobarbital were given. The child was transferred to a nearby facility with pediatric intensive care capabilities in stable condition. The child did not experience any hypotension or dysrhythmia, and the electrocardiographic QTc and QRS complex were normal throughout the clinical course. During the subsequent 48 h, the child awoke and regained normal function. This child's recovery was uneventful, and the child was discharged home without sequelae. Plasma levels of citalopram were 1400 ng/ml, 583 ng/ml, 416 ng/ml, and 296 ng/ml, at one, six, 13, and 23 h post-ingestion, respectively. The first level likely represents a predistributional level with subsequent levels giving an elimination t1/2 of 17.38 h. CONCLUSION: We report a case of citalopram poisoning in a 10-month-old infant with refractory seizures, and an absence of cardiovascular events with subsequent excellent outcome. The elimination of the parent drug corresponds to an approximate t1/2 of 15-20 h in this single case.