A report of acute atrial fibrillation induced by misapplication of epinephrine

AbstractUrticaria is a systemic allergic reaction leading to wheal formation with skin itching. Occasionally we come across some intractable cases, in which we may administrate epinephrine infusion besides steroid and anti-histamine. A 19 year-old man suffered from intractable urticaria for 2 days, although anti-histamine and steroids were used. Titration of adrenaline was considered in the treatment of intractable urticaria. He was administrated 1 mg epinephrine intravenous bolus due to mis-dilution by the nurse. Transient atrial fibrillation with cardiac ischemia occurred. After 12.5 mg labetalol i.v., and 11-hour observation in the emergency room, he gradually recovered to normal sinus rhythm without ST-T change. In the past, ventricular tachycardia, hypertension, chest pain, pulmonary edema, the need to intubate, renal failure requiring renal transplant, coronary artery spasm, myocardial ischemia/infarction and hypokalemia have been reported after mis-diluted or excessive doses of epinephrine in treating anaphylaxis. To our knowledge, our case is the first worldwide to describe transient atrial fibrillation after epinephrine overdose, and the patient was successfully resuscitated by 12.5 mg labetalol. It is important to know how to rescue accidental epinephrine intravenous injection patients

Radiographic Disclosure of Fournier’s Gangrene

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Intra-abdominal abscess caused by toothpick injury

SummaryWe present the case of a 42-year-old female who presented to our emergency department (ED) complaining of epigastric pain for four days. She had been seen in the outpatient department and ED previously for evaluation, but continued to experience epigastric pain with fever. Emergency panendoscopy was performed and a toothpick was discovered impacted in the duodenal bulb. The gastroenterologist was unable to remove the toothpick endoscopically. Computed tomography of the abdomen revealed a long and straight hyperdense foreign body, and intra-abdominal abscess formation. An emergency laparotomy was performed. The patient recovered gradually and was discharged 11 days later. She could not remember when she swallowed the wooden toothpick, but guessed that it was while out drinking. There is an old wives’ tale in Taiwan that putting a toothpick in the cup while drinking beer reduces the likelihood of abdominal distention from the carbonation of the beer

Sonographic Detection of Pseudoaneurysm in Vascular Injury in Emergency Department

A 31-year-old man suffered from a stab wound to the lower extremity. The patient had a hard sign of a vascular injury (a diminished distal pulse) and therefore probably should have undergone operative repair, but refused. One week later, he returned to our emergency department with a painful right thigh swelling. Bedside sonography was used to detect a pseudoaneurysm. Emergency sonography is a fast, non-invasive, and rapid decision-making approach in emergency practice

Treat the patient by the recognized toxidrome when the ingested herbal juice is non-toxic

This is the case of 63-year-old mother and her 35-year-old daughter who drank herbal juice (Rhizoma Dioscoreae Nipponicae and Ficus formosana Maxim) and then developed diarrhea, cold sweating, and myoclonus. On physical examination, the mother had a normal consciousness level, a normal respiratory rate, and bilateral miosis. After the administration of 2 g of pralidoxime (PAM) and 0.5 mg of atropine, the mother felt better. The daughter only had mild symptoms of sweating and vomiting before arrival at the emergency department (ED)

Out-of-hospital Cardiac Arrest in the Elderly

SummaryBackgroundTo investigate the characteristics of out-of-hospital cardiac arrest (OHCA) in the elderly, we retrospectively studied a 6-month series of cases in an emergency department (ED) of a medical center in northern Taiwan.MethodsThere were 145 OHCA cases sent to our ED from January 1, 2007 to June 30, 2007. Of these, 28 traumarelated and five pediatric cases were excluded, and 112 cases were eventually enrolled into our study. The 112 cases were divided into an elderly group (≥ 65 years) of 81 cases and a non-elderly group of 31 cases. There were 64 males and 48 females (male/female ratio, 1.33:1) aged 24–99 years. We collected the laboratory data and made comparisons between the elderly and non-elderly group in arterial blood gas, hemoglobin, potassium, glucose, and troponin I. We used the statistical software SPSS version 11.5.0 (SPSS Inc., Chicago, IL, USA) with t test analysis. The clinical significance was set at p < 0.05.ResultsReturn of spontaneous circulation (ROSC) occurred in 46 cases (41%) after standard resuscitation by advanced cardiac life support. The elderly group had a higher ROSC rate than the non-elderly group, but this was not significant (44% vs. 32%; p = 0.335). The elderly group had less acidosis, less hypercapnia, less hyperkalemia, less hyperglycemia and a higher rate of elevated troponin I than the non-elderly group, but the differences were not significant. The elderly group had significantly lower hemoglobin levels than the non-elderly group (10.52 ± 3.04 vs. 12.6 ± 3.32g/dL; p = 0.003). The glucose levels of the ROSC group were significantly higher than the non-ROSC group in the elderly (230.14 ± 130.4 vs. 195.1 ± 147.7mg/dL; p = 0.049). In the group of acute coronary syndrome (ACS)-related OHCA, the ROSC rate in the elderly group was significantly higher than that of the non-elderly (54.2% vs. 40%; p = 0.014). The elderly group had a slightly lower rate of survival than the non-elderly group (7.4% vs. 9.7%; p = 0.159).ConclusionThe elderly OHCA cases had an anemic status. The elderly had a higher ROSC rate in cases with relative hyperglycemia and ACS-related OHCA. This finding provides us with the theory of trialing administration of glucose water during resuscitation in OHCA cases

Ruptured Aortic Aneurysm Presenting as a Stridor

SummaryStridor is an abnormal, high-pitched, whining breathing sound caused by a blockage in the throat or larynx that is usually heard in children. We describe an unusual case of an 81-year-old man brought to our emergency department with sudden onset of dyspnea and shortness of breath. Stridor could be heard without a stethoscope. We found a huge mass over the left upper chest on chest radiography, suggesting an aortic aneurysm. We believed that these symptoms were caused by a huge thoracic aortic aneurysm with trachea/bronchi compression. Chest computed tomography confirmed the diagnosis

Selectively enhanced expression of prophenoloxidase activating enzyme 1 (PPAE1) at a bacteria clearance site in the white shrimp, Litopenaeus vannamei

<p>Abstract</p> <p>Background</p> <p>The prophenoloxidase-activating (PO activating) system plays an important role in the crustacean innate immunity, particularly in wound healing and pathogen defense. A key member of this system is prophenoloxidase-activating enzyme (PPAE), which is the direct activator of prophenoloxidase (proPO). Despite their importance in crustacean PO activating system, the studies on them remain limited.</p> <p>Results</p> <p>Here we report on a PPAE of white shrimp, <it>Litopenaeus vannamei </it>(lvPPAE1), which showed 94% similarity to PPAE1 of <it>Penaeus monodon</it>. We found that lvPPAE1 in fluid hemocytes was down regulated after challenge by <it>Vibrio harveyi </it>but was enhanced when shrimps were exposed to a bacteria-rich environment for long-term. In <it>vivo </it>gene silence of lvPPAE1 by RNAi can significantly reduce the phenoloxidase activity (PO) and increase the susceptibility of shrimps to <it>V. harveyi</it>. Although lvPPAE1 was down-regulated in fluid hemocytes by <it>Vibrio </it>challenge, its expression increased significantly in gill after bacteria injection, which is the primary bacteria-clearance tissue.</p> <p>Conclusion</p> <p>Suppressed expression in fluid hemocytes and enhanced expression in gill indicates selectively enhanced expression at the bacterial clearance site. This is a novel feature for PPAE expression. The results will contribute to our understanding of the PO activating system in crustaceans.</p