1/8. Breath-holding-like spells in an infant: an unusual presentation of lingual thyroglossal duct cyst.The authors report the case of an infant with a lingual thyroglossal duct cyst who presented with breath-holding-like spells, which actually represented life-threatening ball-valve obstruction of the larynx, leading to hypoxemia and transient cerebral dysfunction. When evaluating apparent breath-holding spells in young infants, physicians should include dynamic, episodic upper airway obstruction in the differential diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/8. Lethal enterovirus-induced myocarditis and pancreatitis in a 4-month-old boy.After inconspicuous pregnancy and birth, a 16-year-old mother presented her male baby 5 days later with severe diarrhoea and vomiting. During the following weeks, the child temporarily showed hypotension, hypothermia and increased body temperature, bradyarrythmia with apnoea, continuing diarrhoea, sometimes vomiting and developed signs of pancreatic insufficiency. Due to increasing loss of weight and obviously severe dystrophia, parenteral nutrition had to be initiated. All clinical investigations revealed no underlying disease. Numerous biopsies, mainly from the gastrointestinal tract were taken, but no relevant pathological findings were disclosed. The baby was found lifeless by his mother, 4 months after birth. According to the death certificate, the physicians regarded the lethal outcome as a case of sudden infant death syndrome (SIDS). Histological and immunohistochemical investigations of organ samples revealed signs of myocarditis, pancreatitis and focal pneumonia. Molecularpathological techniques were used to detect enterovirus rna from tissue samples from the myocardium, liver and pancreas. Enteroviral myocarditis with concomitant pancreatitis was determined as cause of death.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/8. Ethical and legal aspects of the emergency management of brain death and organ retrieval.patients brought to an emergency room with profound brain damage can be determined to be unsalvageable but usually cannot be declared brain dead. Most such patients should be admitted to the hospital for physiologic support and formal brain death determination. There are ethical and legal justifications, discussed in this article, for physicians to encourage the families of such patients to consent for them to be organ and tissue donors.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/8. apnea and factitious illness (Munchausen syndrome) by proxy.OBJECTIVE. munchausen syndrome by proxy (MSP) is recognized in the differential diagnosis of apparent life-threatening events, but the early signs and the full spectrum of this presentation are not well recognized. We aim to describe MSP presenting with apnea to illustrate this spectrum and the evolution in our management over a period of 10 years. patients AND RESULTS. Eleven children in five families seen in one institution and assessed by one team are described in detail. The children had apnea and/or pallor, but with a wider age range than usually seen with apparent life-threatening events, sometimes associated with other injuries, and a large percentage of parents were health care providers. In no case was apnea witnessed by health care professionals other than the parents. There were frequent disagreements in management between professionals and, consequently, delays in considering the diagnosis at first. There were two deaths. A team developed, allowing the diagnosis of MSP to be considered sooner and the cases to be assessed and managed consistently. CONCLUSION. MSP is part of child abuse, and it needs to be recognized by all physicians. family assessment is required and the development of a team interested in MSP facilitates assessment and management.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/8. Another false alarm? apnea monitor activation in a Neonatal Intensive Care Unit graduate.Neonatal emergencies have become more common as increasingly sophisticated Neonatal intensive care units graduate lower birth-weight babies born at younger gestational ages. These patients present a number of challenges to emergency physicians. They are often discharged with apnea monitors, which generate a high number of false alarms. Neonatal Intensive Care Unit graduates, however, are predisposed to a number of conditions that can result in true episodes of apnea. We present such a case and will discuss the unusual underlying cause of apnea, the utility of apnea monitors, and the need for emergency physicians to be prepared to evaluate and treat these potentially complicated patients.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
6/8. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1,022 cases.STUDY OBJECTIVE: To determine the safety of intramuscular ketamine when administered by emergency physicians for pediatric procedures in accordance with a defined protocol. methods: We assembled a consecutive case series of children aged 15 years or younger who were given ketamine in the emergency departments of a university medical center and an affiliated county hospital over a 9-year period. A protocol for ketamine use (4 mg/kg, intramuscularly) was followed. Treating physicians were instructed to complete data forms recording complications and adequacy of sedation concurrent with patient care. Subsequent chart review was used to determine indications, adjunctive drugs, time to discharge, and adverse reactions for all patients. RESULTS: Intramuscular ketamine was administered 1,022 times, mainly for laceration repair and fracture reduction. physicians completed data forms for 431 of treated children (42%). Transient airway complications occurred in 1.4%: airway malalignment (n = 7), laryngospasm (n = 4), apnea (n = 2), and respiratory depression (n = 1). All were quickly identified and treated without intubation or sequelae. Emesis occurred in 6.7%, without evidence of aspiration. Mild recovery agitation occurred in 17.6%, moderate to severe agitation in 1.6%. No child required hospitalization for complications caused by ketamine. ketamine produced acceptable sedation in 98% of patients. The median time from injection to emergency department discharge was 110 minutes for children given a single dose of ketamine. CONCLUSION: Intramuscular ketamine may be administered safely by emergency physicians to facilitate pediatric procedures in accordance with a defined protocol and with appropriate monitoring. ketamine is highly effective, has a wide margin of safety, does not require intravenous access, and uniquely preserves protective airway reflexes.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
7/8. A 9-month-old with bradycardia and periodic apnea.The patient was discharged approximately 36 hours after admission to the emergency department. At that time she was awake and alert and responding appropriately to her surroundings. Her vital signs were within normal limits. It took approximately 2 weeks to receive the baby's clonidine level, which was 11.0 ng/mL; the therapeutic level is between 0.5 to 4.5 ng/mL. We came to the conclusion that the babysitter's clonidine patch had accidentally fallen into the playpen, where the baby subsequently sucked on it. To this day, the babysitter denies any involvement. Situations such as this confront emergency nurses every day, and questions arise regarding intent. In this case, the physician interviewed the babysitter and believed that the overdose was unintentional. Once again we are reminded of the fragility of life, the importance of capable, cautious caregivers, and just how easily accidents can happen. What a happy outcome this turned out to be after what appeared to be such a grave medical emergency on presentation!- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/8. The intubating laryngeal mask: use of a new ventilating-intubating device in the emergency department.The intubating laryngeal mask airway (ILM) was introduced in 1997 as a modification of the classic laryngeal mask airway. In addition to serving as an elective or emergency ventilating device, it is designed to allow blind intubation. We report 3 cases of airway management in the emergency department of Yale-New Haven Hospital where the ILM was used to establish ventilation and intubation in patients in whom direct laryngoscopy had failed. The 3 cases are representative of situations commonly seen in the ED: the obtunded and apneic ("crash airway") patient, failed rapid sequence intubation, and the recognized difficult airway/awake intubation. In all 3 cases, a clear airway was established on initial placement of the ILM, and intubation was achieved on the first attempt at blind advancement of the endotracheal tube. Although the ILM may be an important addition to the armamentarium of the emergency physician, proficiency in its use requires practice under controlled conditions. We suggest that the emergency physician seek out elective practice in either a teaching workshop or hospital operating theater.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |