Veronica Tucci

The clinical manifestations, diagnosis, and treatment of adrenal emergencies.

Emergency medicine physicians should be able to identify and treat patients whose clinical presentations, including key historical, physical examination, and laboratory findings are consistent with diagnoses of primary, secondary, and tertiary adrenal insufficiency, adrenal crisis, and pheochromocytoma. Failure to make a timely diagnosis leads to increased morbidity and mortality. As great mimickers, adrenal emergencies often present with a constellation of nonspecific signs and symptoms that can lead even the most diligent emergency physician astray. The emergency physician must include adrenal emergencies in the differential diagnosis when encountering such clinical pictures.

Down the Rabbit Hole: Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies.

Patients presenting with behavior or psychiatric complaints may have an underlying medical disorder causing or worsening their symptoms. Misdiagnosing a medical illness as psychiatric can lead to increased morbidity and mortality. A thorough history and physical examination, including mental status, are important to identify these causes and guide further testing. Laboratory and ancillary testing should be guided by what is indicated based on clinical assessment. Certain patient populations and signs and symptoms have a higher association with organic causes of behavioral complaints. Many medical problems can present with or exacerbate psychiatric symptoms, and a thorough medical assessment is imperative.

A Modern-Day Fight Club? The Stabilization and Management of Acutely Agitated Patients in the Emergency Department

This article is an overview of the treatment and management of acutely agitated patients as they present in the emergency department or emergency psychiatric facility. This article focuses on how a patient encounter may unfold and what issues need to be considered along the way. Verbal de-escalation is emphasized as a standard of care, including the offering of environmental changes and medications when indicated. Approved medications are reviewed as well as the proper use of restraints.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 2: Special Psychiatric Populations and Considerations

Patients who present to the emergency department (ED) with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, there are wide variations in quality of care for these individuals. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach to patients. Our group has long advocated a dynamic comanagement approach for medical clearance in the ED, and this article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical/physical examination, and common pitfalls in the medical clearance process.

Shift, Interrupted: Strategies for Managing Difficult Patients Including Those with Personality Disorders and Somatic Symptoms in the Emergency Department

Difficult patients are often those who present with a mix of physical and psychiatric symptoms, and seem refractory to usual treatments or reassurance. such patients can include those with personality disorders, those with somatization symptoms; they can come across as entitled, drug-seeking, manipulative, or simply draining to the provider. Such patients are often frequent visitors to Emergency Departments. Other reasons for difficult encounters could be rooted in provider bias or countertransference, rather than sole patient factors. Emergency providers need to have high awareness of these possibilities, and be prepared to manage such situations, otherwise workup can be sub-standard and dangerous medical mistakes can be made.

Role of point of care - ST2, Galectin-3 and adrenomedullin in the evaluation and treatment of emergency patients.

There have been many technological advances improving the work up and treatment of patients in the emergency department (ED). Point of care testing (POCT) is becoming more common, especially in the time compressed clinically high-pressured environment of the emergency department. In present times, emphasis of POCT has spurred search of novel biomarkers which promise earlier and more specific detection of disease. This article reviews the role of ST2, Galectin-3 and Adrenomedullin in the acute care setting addressing the screening, diagnostic, and prognostic role of each marker for stratification of patients. Use of these markers has shown a strong correlation with early identification and efficient management in the ED.

Difficult Patients in the Emergency Department: Personality Disorders and Beyond

Physician-patient encounters in clinical settings, especially in the emergency department, can be of varying degrees of difficulty. Medically complicated, challenging cases can be paradoxically rewarding, whereas psychologically driven difficulty is frustrating and counterproductive for patient care. This article presents 3 different complementary perspectives on difficult patients: clinical presentations, manifestations of personality traits and disorders in clinical settings, and how physician feelings may affect care. Management strategies are discussed.

Emergency Department Medical Clearance of Patients with Psychiatric or Behavioral Emergencies, Part 1

Patients presenting to the emergency department with mental illness or behavioral complaints merit workup for underlying physical conditions that can trigger, mimic, or worsen psychiatric symptoms. However, interdisciplinary consensus on medical clearance is lacking, leading to wide variations in quality of care and, quite often, poor medical care. Psychiatry and emergency medicine specialty guidelines support a tailored, customized approach. This article summarizes best-practice approaches to the medical clearance of patients with psychiatric illness, tips on history taking, system reviews, clinical or physical examination, and common pitfalls in the medical clearance process.

Like the eye of the tiger: Inpatient Psychiatric facility exclusionary criteria and its “Knockout” of the emergency psychiatric patient

Context: Over 6% of all emergency department (ED) visits in the United States involve primary mental health or behavioral issues. The patients are stabilized in the ED but frequently require admission to an inpatient psychiatric unit or institution for longer term treatment and management. To facilitate this process, an emergency physician (EP) must first “medically clear” the patient as stable for transfer. At present, there is no interdisciplinary consensus regarding the necessary elements of the medical clearance or stability assessment process. In addition to satisfy the vague requirement for medical clearance, the EP must abide by the rules of the inpatient facilities before his/her patient is accepted. Settings and Design: This manuscript summarizes the admission exclusionary criteria of inpatient psychiatric units in the Houston–Galveston metro area. Subjects and Methods: we pooled the exclusionary criteria of all the facilities patients with mental illness can be sent to in the Houston-Galveston metropolitan area, and divided those criteria by categories. Results: Pooled exclusionary criteria congregate into 1. preexisting or current medical condition and capabilities (e.g. hypertensive urgency, pregnancy, acute alcohol intoxication), 2. exclusionary criteria related to administrative burdens that may impact staffing or require advanced equipment/training e.g. autism spectrum disorders, intellectual disabilities, respiratory isolation or daily hemodialysis, 3. laboratory and ancillary testing required by inpatient facilities before acceptance of the patient. Conclusions: Of the inpatient units in the Houston-Galveston area, facilities lack a unified staffing model, ancillary services, but the various challenges (e.g., limited staffing and ancillary services) and different skills offered (e.g., geriatric care) are reflected in exclusionary criteria in a partially overlapping, but not fully uniform, way. The variation in number and kinds of exclusionary criteria further complicate the admission process and often serve as a bottleneck in the securing an inpatient bed.

Synthetic Cannabinoids and Dysphonia: A Case Report

Synthetic cannabinoids (SC) have been increasing in popularity throughout the past decade, and are now mainstream drugs of abuse. Undetectable by many urine drug screens, SC are a heterogeneous group of chemicals with various documented side effects including myocardial infarctions, tachycardia, agitation, psychosis, nausea, and vomiting. Methods: In this case report, we present a 38 year-old female with dysphonia secondary to SC. Our patient developed dysphonia after 2.5 years of regular SC use. She was thoroughly evaluated by her primary care physician and referred to both, otorhinolaryngology and pulmonology, with an exhaustively negative workup. Her dysphonia persisted for 13 months and only improved after she abstained from using SC. Conclusions and Significance: We could find no previous cases of dysphonia or hoarseness attributed t SC use/ abuse in the literature and is yet another kind of health sequelae frontline providers should look for in chronic users of SC. The previously unrecognized relationship between SC and dysphonia demonstrates our limited understanding of the chemicals’ adverse effects. Just as nicotine affects the larynx and causes dysphonia and laryngeal carcinoma, this case also raises the question of whether the chemical composition of SC affects the larynx in the same way and its use leads to an increased risk of laryngeal cancer for users/abusers