Sarcoidosis.

Sarcoidosis has a multitude of manifestations and affects the human body widely. Pulmonary complaints are most common; however, cardiac, optic, and neurologic manifestations carry high mortality and morbidity. Acute presentations in the emergency room can cause life-altering effects if not appropriately diagnosed and treated. Generally, less severe cases of sarcoidosis have a favorable prognosis and can be treated with steroid therapy. Resistant and more severe cases of the disease carry high mortality and morbidity. It is incredibly important to arrange specialty follow-up for these patients when needed. This review focuses on the acute presentations of sarcoidosis.

Sarcoidosis.

Sarcoidosis has a multitude of manifestations and affects the human body widely. Pulmonary complaints are most common; however, cardiac, optic, and neurologic manifestations carry high mortality and morbidity. Acute presentations in the emergency room can cause life-altering effects if not appropriately diagnosed and treated. Generally, less severe cases of sarcoidosis have a favorable prognosis and can be treated with steroid therapy. Resistant and more severe cases of the disease carry high mortality and morbidity. It is incredibly important to arrange specialty follow-up for these patients when needed. This review focuses on the acute presentations of sarcoidosis.

Acute Optic Neuritis Diagnosed by Bedside Ultrasound in an Emergency Department.

BACKGROUND: Transorbital ultrasound was used to diagnose acute optic neuritis (AON) at bedside in an emergency department (ED). CASE REPORT: A 59-year-old female patient presented to an ED after 7 days of progressive unilateral visual loss while she was receiving outpatient treatment for relapsing-remitting multiple sclerosis. Transorbital ultrasound revealed a disparity between the optic nerve sheath diameters of the affected and nonaffected eyes and striking optic nerve edema in the affected eye. These findings led to a diagnosis of AON and early definitive treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given an absence of reliable diagnostic criteria for AON, comorbidity with multiple sclerosis, and limitations inherent to magnetic resonance imaging, transorbital sonography may facilitate diagnosis of this condition in emergent presentations.

Evidence-Based Clinical Criteria for Computed Tomography Imaging in Odontogenic Infections.

PURPOSE: Odontogenic infections are a common problem in emergency departments and impose a burden on hospital budgets and provider time. Compounding this is the lack of evidence guiding the patient's initial evaluation. The purpose of this study was to derive evidence-based guidelines for the use of computed tomographic (CT) imaging in the management of odontogenic infections. MATERIALS AND METHODS: A prospective cohort study was designed. Patients with an odontogenic infection presenting to the emergency department from November 1, 2016 to November 30, 2017 were eligible for inclusion. The outcome variable was need for CT imaging, which was based on the location of the abscess. The potential predictor variables were demographics, history items, examination findings, and laboratory values. The association between the outcome and predictor variables was determined using classification and regression tree analysis and standard logistic regression analysis. RESULTS: There were 129 patients who met the inclusion criteria and consented to participation. The patients were 53.5% men and the mean age was 42.5 years. The most common fascial spaces involved were vestibular (58.2%), submandibular (18.6%), pterygomandibular (6.2%), buccal (5.4%), and lateral pharyngeal (5.4%). The classification and regression tree analysis identified mandibular inferior border blunting at the body as the best predictor for necessitating a CT scan and identified a mouth opening smaller than 25 mm as the second best predictor. These 2 predictors had an accuracy of 96.9% for needing a CT scan. The logistic regression analysis identified these 2 variables and odynophagia, floor of mouth induration, and white blood cell count as relevant predictors for needing CT imaging. CONCLUSION: The 2 physical examination findings of mandibular inferior border blunting at the body and restricted mouth opening were found to be strongly associated with the need for CT imaging. Further studies should be directed at validating these criteria in larger multicenter studies.

Management of Acute Exacerbation of Asthma and Chronic Obstructive Pulmonary Disease in the Emergency Department.

Acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations are the most common respiratory diseases requiring emergent medical evaluation and treatment. Asthma and COPD are chronic, debilitating disease processes that have been differentiated traditionally by the presence or absence of reversible airflow obstruction. Asthma and COPD exacerbations impose an enormous economic burden on the US health care budget. In daily clinical practice, it is difficult to differentiate these 2 obstructive processes based on their symptoms, and on their nearly identical acute treatment strategies; major differences are important when discussing anatomic sites involved, long-term prognosis, and the nature of inflammatory markers.

Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department.

BACKGROUND: Diltiazem (calcium channel blocker) and metoprolol (beta-blocker) are both commonly used to treat atrial fibrillation/flutter (AFF) in the emergency department (ED). However, there is considerable regional variability in emergency physician practice patterns and debate among physicians as to which agent is more effective. To date, only one small prospective, randomized trial has compared the effectiveness of diltiazem and metoprolol for rate control of AFF in the ED and concluded no difference in effectiveness between the two agents. OBJECTIVE: Our aim was to compare the effectiveness of diltiazem with metoprolol for rate control of AFF in the ED. METHODS: A convenience sample of adult patients presenting with rapid atrial fibrillation or flutter was randomly assigned to receive either diltiazem or metoprolol. The study team monitored each subject's systolic and diastolic blood pressures and heart rates for 30 min. RESULTS: In the first 5 min, 50.0% of the diltiazem group and 10.7% of the metoprolol group reached the target heart rate (HR) of <100 beats per minute (bpm) (p < 0.005). By 30 min, 95.8% of the diltiazem group and 46.4% of the metoprolol group reached the target HR < 100 bpm (p < 0.0001). Mean decrease in HR for the diltiazem group was more rapid and substantial than that of the metoprolol group. From a safety perspective, there was no difference between the groups with respect to hypotension (systolic blood pressure < 90 mm Hg) and bradycardia (HR < 60 bpm). CONCLUSIONS: Diltiazem was more effective in achieving rate control in ED patients with AFF and did so with no increased incidence of adverse effects.