My mother is looking blue / 世界急诊医学杂志（英文）

@#A 76-year-old Chinese female presented by ambulance to the Emergency Department complaining of dizziness, headache and fatigue. Her son claimed that the patient “turned blue” three hours prior to onset of the patient’s symptoms. Paramedics noted the patient’s SpO2 was 83% on room air with no improvement with a non- rebreather mask. Past medical history was significant for diabetes and hypertension. Family, social and medication history were non-contributory. Patient denied ingestion of any traditional Chinese medicines but did have some choy sum (a variety of green vegetable) for lunch five hours prior to arrival. On examination, the patient appeared agitated, but alert. Purple lips and fingers were noted (Figure 1). Physical examination: heart rate 55 beats/minute, pulse oximetry 87%, respiratory rate 16 breaths/minute, blood pressure 143/51 mmHg. Bedside investigations: chest X-ray (clear lung fields and cardiomegaly); ECG (sinus rhythm, slight bradycardia at 53 beats/minute); hemoglobin 9.3 g/dL; glucose 10.9 mmol/L (196.2 mg/dL).

Prompt diagnosis of ST-elevation myocardial infarction with papillary muscle rupture by point-of-care ultrasound in the emergency department

A previously healthy 61-year-old man presented to the emergency department with chest pain and dyspnoea for 6 hours. Examination revealed distress with an apical pansystolic murmur. Initial electrocardiogram showed sinus tachycardia and ST elevation in leads II, III, and aVF compatible with an inferior ST-elevation myocardial infarction. Point-of-care echocardiography in the emergency department showed a flail anterior mitral leaflet and severe mitral regurgitation, leading to a provisional diagnosis of papillary muscle rupture. Emergency cardiac catheterization showed 100%, 80%, and 70% occlusion of the middle right coronary, left anterior descending, and left circumflex arteries, respectively. An emergency triple vessel coronary artery bypass grafting and mitral valve replacement was performed. Posteromedial papillary muscle rupture resulting in mitral regurgitation was confirmed intraoperatively. The patient recovered uneventfully. In the absence of primary percutaneous coronary intervention, thrombolysis decisions should be made with extreme caution if mechanical complications of ST-elevation myocardial infarction are suspected.