Adult Congenital Heart Disease in the Emergency Department.

While congenital heart disease historically was a pathology primarily restricted to specialized pediatric centers, advances in technology have dramatically increased the number of people living into adulthood, the number of complications faced by these patients, and the number of patients visiting non-specialized emergency departments for these concerns. Clinicians need to be aware of the issues specific to patients' individual congenital defects but also have an understanding of how typical cardiac pathology may manifest in this special group of patients. This manuscript attempts to provide an overview of this diverse but increasingly common group of adult patients with congenital heart diseases, including a review of their anatomical variants, the complications they face at the highest rates, and ways that emergency physicians may need to manage these patients differently to avoid causing harm.

Acute Brachial Artery Occlusion on Point-of-Care Ultrasound in the Emergency Department: A Case Report.

INTRODUCTION: This is a case report of an acute right brachial artery occlusion found on point-of-care ultrasound in the emergency department (ED) that illustrates the developing role of ultrasound in rapid differentiation and identification of acute vascular emergencies. CASE REPORT: An 87-year-old male with a past medical history of coronary artery bypass graft presented to the ED with acute right upper extremity pain, with point-of-care ultrasound (POCUS) findings consistent with acute right brachial artery occlusion. CONCLUSION: Arterial occlusions are vascular emergencies that can be rapidly identified on POCUS.

Life-threatening Development of Cardiac Tamponade in the Span of 24 Hours.

Cardiac tamponade is a medical emergency that requires immediate treatment. Caused by the development of fluid in the pericardial space, it can result in a severe decrease in cardiac output. When encountering patients with severe hypotension and tachycardia, emergency physicians must always consider the diagnosis of tamponade to facilitate prompt and effective treatment and stabilization. We report our experience with a patient who developed life-threatening cardiac tamponade within a span of less than 24 hours.

Life-Threatening Pancreatitis in Jehovah's Witness Patients With Severe Anemia Treated Without Transfusions and by Interventional Radiology Techniques.

Blood transfusions in anemic patients frequently are used for critically ill patients as a life-saving therapeutic maneuver. Jehovah's Witness (JW) patients typically refuse blood transfusions due to religious beliefs. Numerous clinical reports, in a wide spectrum of medical specialties, have shown no greater morbidity or mortality in JW patients or others who refused transfusions compared to those patients who accept transfusions. We report our experience with two JW patients who presented with severe anemia and life-threatening pancreatitis. Despite undergoing percutaneous drainages by interventional radiology (IR) for complex pancreatic collections (and other IR drainages), neither patient suffered any adverse effect from the IR procedures, even though they refused blood transfusions. Our experience suggests that IR procedures also may be successful with this more limited blood product protocol.

Life-Threatening Reaction with Topical 5-Fluorouracil.

A 67-year-old man developed a suspected adverse drug reaction during treatment with topical 5-fluorouracil (5-FU) for multiple actinic keratosis of the face, neck, and forearms. The man received topical 5-FU at a dosage of 0.5% for the actinic keratoses. After 1 week, he developed extreme lethargy, fatigue, fever, and mouth erosions. Several days later, and after discontinuation of 5-FU, painful mucositis and systemic side effects occurred, meeting criteria for hospitalization because of dehydration and a 6.8 kg weight loss. Hematology/oncology was consulted, and a possible systemic 5-FU reaction, similar to reactions to intravenous chemotherapy seen with a dihydropyrimidine dehydrogenase deficiency was suggested. The patient was not taking any concurrent medications, and he refused dihydropyrimidine dehydrogenase deficiency testing.

Leather Contains Cobalt and Poses a Risk of Allergic Contact Dermatitis: Cobalt Indicator Solution and X-ray Florescence Spectrometry as Screening Tests.

BACKGROUND: Cobalt was recently identified in a leather couch responsible for dermatitis. Cobalt content/release in leather in the United States is unknown. We evaluated leather for cobalt content/release and investigated screening methods for identifying cobalt in leather. METHODS: One hundred thirty-one leather swatches were screened for cobalt content/release with X-ray fluorescence (XRF) spectrometry and cobalt indicator solution (CIS). Samples with positive screens and 1 negative control were analyzed using inductively-coupled plasma mass spectrometry (ICPMS). RESULTS: CIS showed that 5 of 131 samples contained cobalt, subsequently found to be between 1 and 190 parts per million (ppm) when evaluated with ICPMS. The XRF analysis showed that 6 samples contained >5% cobalt, subsequently found to contain greater than 300 ppm cobalt by ICPMS. 7 of 12 tested swatches contained cobalt in excess of 100 ppm. One sample contained greater than 1000 ppm cobalt. The prevalence of swatches containing cobalt at levels in excess of 190 ppm was at least 5% (n = 7; total, N = 131). DISCUSSION: Some leather consumer goods contain and release cobalt. Cobalt indicator solution is a poor screening test for cobalt in leather while XRF screening may be effective. Leather is a new source of cobalt exposure. Exposures to metal allergens are changing in ways that impact clinical decision making.