Jonathan E. Davis

Self-Injectable Epinephrine for Allergic Emergencies

Anaphylaxis is a severe, life-threatening systemic reaction that can affect all ages. Epinephrine is frequently cited as the first-line and single most important agent in the treatment of severe allergic emergencies. Prompt administration of self-injectable epinephrine by patients and caretakers remains a key component in effective out-of-hospital management. This article will review the technique for self-injectable epinephrine administration in allergic emergencies, including discussion of the available dosages and formulations, indications, as well as other issues related to its use.

Thunderclap Headache with Orgasm: A Case of Basilar Artery Dissection Associated with Sexual Intercourse

BACKGROUND Headaches associated with sexual intercourse (coital cephalgia) have many different causes and are often divided in the literature into pre-orgasmic and orgasmic headaches. OBJECTIVE To present a case of orgasmic headache caused by a basilar artery dissection and to present a literature-based guide to the diagnosis and management of patients presenting with headaches related to sexual activity. CASE REPORT We report the case of a 34-year-old man without significant past medical history who presented to the Emergency Department with two episodes of orgasmic headache caused by basilar artery dissection. CONCLUSIONS The cause of headaches related to sexual activity range from the benign to the life-threatening. Due to the dynamics of cerebral blood flow during sexual intercourse, basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm. Appropriate brain imaging and, possibly, lumbar puncture may assist in identifying potentially life-threatening causes of coital headaches.

Serious Infectious Complications Related to Extremity Cast/Splint Placement in Children

BACKGROUND Extremity injuries necessitating splinting or casting are commonly seen in the emergency department (ED) setting. Subsequently, it is not uncommon for patients to present to the ED with complaints related to an extremity cast or splint. OBJECTIVE To present a literature-based approach to the identification and initial management of patients with possible infectious cast/splint complications in the ED setting. CASE REPORTS We present two cases of serious infectious complications arising from extremity cast/splint placement seen in a single pediatric ED: a case of toxic shock syndrome in an 8-year-old child, and a case of necrotizing fasciitis resulting in upper extremity amputation in a 3-year-old child. CONCLUSIONS/SUMMARY A wide spectrum of potential extremity cast/splint infectious complications may be seen, which include limb- or life-threatening infections such as toxic shock syndrome and necrotizing fasciitis. Simply considering these diagnoses, and removing the cast or splint to carefully inspect the affected extremity, are potential keys to early identification and optimal outcome of cast/splint complications. It is also prudent to maintain particular vigilance when treating a patient with a water-exposed cast, which may lead to moist padding, skin breakdown, and potential infection. In patients with suspected serious infections, aggressive fluid management and antibiotic therapy should be initiated and appropriate surgical consultation obtained without delay.

“Forgettable” Sex: A Case of Transient Global Amnesia Presenting to the Emergency Department

BACKGROUND Transient global amnesia is characterized by the sudden development of dense anterograde amnesia, without alteration in level of consciousness and in the absence of focal neurologic deficits or seizure activity. Various precipitating causes have been reported in the medical literature. OBJECTIVE To present a literature-guided approach to the diagnosis and management of transient global amnesia in the Emergency Department (ED). CASE REPORT We report the case of a 54-year-old woman who presented to the ED with an episode of acute memory loss. CONCLUSIONS Although rare, transient global amnesia may present in a dramatic fashion. The occurrence of a distinct precipitating event and repetitive questioning seem to be key features in making the diagnosis. Important differential considerations include transient ischemic attack, seizure, and subarachnoid hemorrhage. Brain imaging and specialty consultation are reserved primarily for patients with unclear circumstances, altered level of consciousness, focal neurologic findings, and persistent (or very brief) amnestic symptoms. Brain imaging may, however, relieve anxiety about more dangerous causes of the event.

An Unusual Cause of Neck Pain: Acquired Chiari Malformation Leading to Brainstem Herniation and Death

BACKGROUND Chiari malformations are structural defects in which portions of the cerebellum are located below the foramen magnum. Of the four types of Chiari malformation, emergency physicians are most likely to encounter Type I (Chiari I). Chiari I malformations may be congenital or acquired. Congenital Chiari I malformations are most frequently encountered in the emergency department (ED) setting due to an exacerbation of subacute or chronic Chiari-related symptoms. However, acute Chiari-associated symptoms from an occult congenital or a secondary (acquired) Chiari malformation may occur. OBJECTIVE To present a literature-guided approach to the identification and initial management of patients with Chiari I malformations in the ED setting. CASE REPORT We present the case of a 30-year-old man who presented to the ED with isolated cervical region pain, and who subsequently died as a result of acute brainstem herniation from an acquired Chiari I malformation. CONCLUSIONS Although rare, acute Chiari I malformation may present to the ED. The new finding of a Chiari I malformation should be presumed acquired until proved otherwise, and should trigger an evaluation for central nervous system lesions or hydrocephalus. Brain imaging to exclude increased intracranial pressure and, in certain cases, specialty consultation, are important considerations.

Pediatric Genitourinary Emergencies

Pediatric medical complaints and differential diagnoses often vary from adults, requiring a specialized knowledge base and behavioral skill set. This article addresses a variety of congenital and acquired pediatric genitourinary disorders. Genitourinary emergencies include paraphismosis, priapism, serious infection, significant traumatic injury and gonadal torsion.

Visual Diagnosis: Quadriceps Tendon Rupture

*MedStar Georgetown University Hospital & MedStar National Rehabilitation Hospital, Washington, DC, †Department of Radiology, MedStar Washington Hospital Center, Washington, DC, and ‡Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC Corresponding Address: Jonathan E. Davis, MD, Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC 20007

Antithrombotic Reversal Agents

The actively bleeding anticoagulated patient presenting to the emergency department requires rapid evaluation and treatment, which is made increasingly complicated by the ever-evolving antithrombotic treatment options used in medicine. Even with excellent supportive care, the timeliness with which reversal decisions need to be made continues to demand of the emergency practitioner a familiarity with the properties and general characteristics of a variety of antithrombotic agents. Reversal options vary and may include vitamin K, FFP, PCC, rFVIIa, platelets, and desmopressin, among others.

Hematology/Oncology Emergencies

Hematologic and oncologic (heme/onc) emergencies are an ever-increasing occurrence in emergency departments (ED) around the world. Our population is aging; more patients are receiving chemotherapy and related treatments, and patients are living longer with chronic heme/onc comorbid conditions. And regardless of training background, many emergency providers (EP) still feel uncomfortable when faced with heme/onc emergencies. In this issue of the Hematology/Oncology Clinics of North America, we cover the most common heme/onc emergencies so that any EP will feel more comfortable with diagnosis, evaluation, and urgent or emergent treatments. We recognize the natural concern that any text on heme/onc emergencies might go too far into the depths of pathophysiology to be relevant to a practicing EP. As such, we have made a concerted effort to balance presenting just enough pathophysiology necessary for context while delivering the essential evaluation and treatment strategies that are necessary for an EP faced with such conditions. To achieve this goal, each article utilizes a combination of charts, tables, images, and algorithms to augment the text and make the material easier to comprehend and incorporate into clinical practice. We have selected the most common, most dangerous, and most challenging heme/ onc emergencies to be covered in this issue of Hematology/Oncology Clinics of North America. Classic emergencies, such as neutropenic fever, tumor lysis syndrome, and superior vena cava syndrome, are covered in addition to a broad review of the presentation and clinical course of the acute leukemias. We also review the most common complications associated with treatments as this will be a more common emergency presentation given the escalating percentage of patients receiving chemotherapeutic and related agents. Heme/onc emergencies unfortunately impact children as well, and these more challenging pathologies and presentations are addressed separately in a dedicated pediatric article.