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- Volume 2014, Issue 1
Journal of Emergency Medicine, Trauma and Acute Care - Volume 2014, Issue 1
Volume 2014, Issue 1
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Lightning injury in a desert
Authors: Nissar Shaikh, Firdous Ummunnisa, Muneer Mahomed and Noora el-TamimiThunderstorms and lightning are uncommon in the Arabian Gulf. Lightning is a giant spark of electricity in the atmosphere or between atmosphere and ground. Most frequently fatalities after the lightning injury are due to direct lightning strike and cardiorespiratory arrest. It is essential that acute care physicians as well as paramedical personnel are aware of lightning injury and its management. This is a case of a field worker who was struck by lightning while working, which led to a cardiorespiratory arrest.
A young male was brought to the emergency room with a history of having been struck by lightning while he was at work in the desert on a roadside project in a thunderstorm. The lightning injury was witnessed by his colleagues and they started immediate basic life support when they found him unconscious without a pulse. He was intubated, ventilated and started on vasopressors in the nearest primary health centre. He was then transferred to an intensive care unit. He was weaned off vasopressors and ventilation by day four and was extubated then transferred to the ward and subsequently discharged home.
Awareness of the danger posed by lightning injury is essential. Early life support is important for better outcome of lightning induced cardiorespiratory arrest.
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ASL/ALT ratio as a triage marker for enteric fever in the emergency department
Objective: Early differentiation of enteric (typhoid) fever from other febrile conditions has been difficult due to the non-specific clinical presentations and lack of substantiating laboratory clues. Transaminase alterations in enteric fever were thought to be non-specific and have not been investigated before in comparison with other febrile conditions with regards to their prevalence and the aspartate amino transferase/alanine amino transferase (AST/ALT) ratio. We sought to examine these parameters as triage markers for enteric fever. Methods: We retrospectively studied 106 patients with enteric fever diagnosed by positive blood culture. 112 febrile patients tested negative for malaria were taken as controls. The controls were matched to the test group with respect to demographic and baseline clinical features. Serum AST, ALT values on first visit to the emergency department was noted and AST/ALT ratio was determined. The values between the test and control groups were compared and the results were analyzed using appropriate statistical methods. Results: The mean AST and ALT levels were found to be significantly higher for enteric fever patients than the control group (109.91 U/L ± 76.07 vs. 29.93 U/L ± 16.74; p < 0.0001) and (83.60 U/L ± 68.04 vs. 32.12 U/L ± 21.79; p < 0.0001) respectively. The mean AST/ALT ratio was found to be higher among enteric fever patients compared to the control group (1.42 ± 0.60 vs.1.07 ± 0.44; p < 0.0001). AST/ALT ratio of ≥ 1 combined with AST of ≥ 40 U/L was found in 72.6% of enteric patients vs. 6.2% in the control group (p < 0.0001). Conclusions: As compared to other common febrile conditions, transaminase alterations in enteric fever seem to follow a specific pattern characterized by higher prevalence of mild elevations (mean levels < 3 fold the upper limit of normal) with a general trend of AST/ALT ratios ≥ 1. In the febrile adult, having an AST/ALT ratio of >1 combined with an AST level of >40 U/L, may provide a simple and cheap triage marker for blood cultures and closer observation especially in the emergency department.
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Management of benign paroxysmal positional vertigo (BPPV) in the emergency department
Authors: Khalid Bashir, Furqan Irfan and Peter A CameronBenign paroxysmal positional vertigo (BPPV) is a common medical condition that can be managed by emergency physicians. Vertigo sufferers usually complain of the room spinning associated with certain head movements such as getting out of bed, looking up and bending down. BPPV can be diagnosed clinically from history and examination and does not require any investigations. BPPV can be effectively treated at the bedside by using one of the Canalith repositioning maneuvers (particle repositioning maneuvers). This treatment has been proven to be effective in randomised controlled trials and carries minimal risks. The common complications during the procedure include nausea, vomiting and vertigo. There are no absolute contraindications. BPPV can resolve spontaneously but symptoms may last for weeks in most patients, to years in others. Failure to respond to physical maneuvers and an unusual pattern of nystagmus may suggest a central pathology. Diagnostic strategies and physical manoeuvres are described in this narrative review. Future directions and recommendations also discussed.
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Critique of “Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population”
Background: Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However, identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population, by comparing those trauma patients who did receive massive transfusion with those who did not. Methods: Between 1985 and 2010, 1,686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic, physiologic, laboratory, injury, and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. Results: MT patients had a higher pulse rate, lower Glasgow Coma Scale (GCS) score, lower systolic blood pressure, lower hemoglobin level, higher Injury Severity Score (ISS), higher international normalized ratio (INR), and longer stay. Initial logistic regression identified base deficit (BD), INR, and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater, a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio, 51.6; 95% confidence interval, 24.9Y95.8). The area under the receiver operating characteristic curve for the model was 0.859. Conclusion: From this study, a combination of BD, INR, and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation.
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Monitoring the treatment of myocardial stunning syndrome after acute carbon monoxide poisoning using arterial pulse wave analysis: a case report
Authors: Vasiliki Soulountsi, Athina Lavrentieva, Vasiliki Karali, Chrysa Nakou and Militsa BitzaniMyocardial injury due to acute carbon monoxide intoxication is often refractory to standard resuscitation methods. Levosimendan is a new inotropic agent that is used in the treatment of acute and chronic heart failure. We report a case of severe cardiopulmonary compromise after exposure to carbon monoxide in a 40-year-old woman who was monitored using transthoracic echocardiography and the arterial pulse contour analysis system (FloTrac) and successfully treated with levosimendan.
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Acute mastoiditis in children in the State of Qatar
Authors: Shihab Mohammed Albaraznji, Khalid Al Ansari and Mayed Mohamed RadiBackground: Acute mastoiditis is a serious complication of otitis media. Its diagnosis and treatment carry a great importance due to its potentially serious consequences. This study was designed to evaluate recent clinical experiences with pediatric acute mastoiditis in the State of Qatar. Our objectives were to highlight the importance of this disease and its possible complications, which emphasize the necessity of early diagnosis and proper treatment. We also assessed the commonality of this condition compared to some other countries as well as explored their experience in this regard. Materials and Methods: This is a retrospective study of all children ≤ 14 years presenting to the pediatric emergency centers (PEC) in the State of Qatar between January 2005 and December 2008, with a clinical diagnosis of acute mastoiditis supported by CT scan findings. Results: Twenty-seven patients were diagnosed with acute mastoiditis during the study period, with a mean age of 5.4 years. Only four children were diagnosed with otitis media and started on antibiotics a few days prior to presentation. The following signs and symptoms recorded on presentation were: fever in 77%, ear pain in 51%, ear discharge in 40%, postauricular swelling in 100%. The most frequent pathogen cultured by ear swab was Pseudomonas aeruginosa (in six out of sixteen patients who presented with ear discharge). One patient needed surgical intervention for mastoid abscess. There were two recorded complications of mastoid abscess in one patient that needed drainage and facial palsy in three patients. No mortality was reported during the study period. Conclusions: Acute mastoiditis in children is not uncommon in the State of Qatar. Full recovery with conservative treatment is noticed in most cases. Pseudomonas aeruginosa is a common pathogen which indicates the need for broader systemic coverage in early diagnosis. Moreover, in order to promote adequate management and prevent inherently severe complications, great care is required from clinicians to reach early diagnosis. Involvement of the otolaryngology physician from the beginning is very significant.