1/25. Economic, ethical, and outcome-based decisions regarding aggressive surgical management in patients with penetrating craniocerebral injury.Each year fatalities in the united states increase as a result of gunshot wounds to the head. This increase, coupled with the progressive limitation of medical and economic resources available at major trauma centers, has brought into question the concept that everything possible should be done to save the lives of victims, who have only a minimal and nonpredictable chance of having a good outcome. Thus, consideration must be given to the economics of treating cranial gunshot wounds and the relationship of this treatment to outcome. When a good outcome can be predicted, treatment should be aggressive. However, when a good outcome cannot be predicted, surgical intervention will have no effect and the potential costs of aggressive treatment must also be considered. Clearly, there are ethical dilemmas involved in withholding operative treatment from any individual, even if there is only a minimal chance of a reasonable neurologic recovery. A negotiation-based approach should be used in determining the medical and ethical benefits of aggressive management strategies. Unfortunately, the care of critically ill patients is inconsistent with this approach. In order to insure that the best decision is made, guidelines dictating when to surgically intervene must be made an essential part of the patient/health care provider negotiation--even in worst case scenarios. The combination of an extremely poor prognosis for these injuries, and economic constraints faced by government-run facilities today could suggest that some patients should be allowed to die. Thus, the physician must be a source of information for the families, providing support and becoming a decision-making partner regarding potential intervention. In each situation, a strict set of guidelines must be formulated to establish a moral foundation for the ultimate mutual decision.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/25. Complications of a retrograde intubation in a trauma patient.The authors report the case of an elder woman involved in a motor vehicle collision (MVC) requiring emergent intubation using the technique of retrograde intubation (RI). Since RI is a blind technique, potential complications arising from its use are numerous and may result in increased morbidity and mortality. Such was the case of this RI that involved incorrect placement of the endotracheal tube (ETT), resulting in suboptimal ventilation and increased morbidity. Additionally, this case illustrates how the failure to detect this error in multiple settings (ambulance, helicopter, emergency department) led to unnecessary and potentially deleterious procedures and significant delay in providing the basics of trauma care, oxygenation and ventilation. Although theoretical complications of RI have been addressed in the past, there have been very few published reports of actual complications. The emergency physician must be aware of difficult airways, options available to establish alternative airways, and methods to confirm appropriate placement of the ETT. The authors also discuss the indications, procedures, and complications involved in performing an RI.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/25. sleep-wake schedule disorder disability: a lifelong untreatable pathology of the circadian time structure.Certain sleep-wake schedule disorders (SWSDs) cannot be successfully managed clinically using conventional methods of sleep therapy. We describe two cases of SWSD, the first following head trauma and the second originating during childhood, that had been misdiagnosed by physicians for many years. After conventional treatment for SWSD with light therapy and melatonin failed to bring about substantial improvement, it was determined that they were suffering from an incurable disability. Hence, we propose new medical terminology for such cases--SWSD disability. SWSD disability is an untreatable pathology of the circadian time structure. patients suffering from SWSD disability should be encouraged to accept the fact that they suffer from a permanent disability, and that their quality of life can only be improved if they are willing to undergo rehabilitation. It is imperative that physicians recognize the medical condition of SWSD disability in their patients and bring it to the notice of the public institutions responsible for vocational and social rehabilitation.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
4/25. Penetrating trauma to the head and neck from a nail gun: a unique mechanism of injury.Published reports of nail gun injuries to the head and neck are rare. We describe the cases of three patients who sustained nail gun injuries to the head and who were managed at our institution. All patients were treated successfully and all recovered with minimal morbidity. Any physician who is called on to manage a nail gun injury to the head or neck should understand that most likely the patient will have sustained a surprisingly limited amount of tissue injury, owing to the relatively low velocity of the projectile compared with that delivered by firearms. Computed tomography and selective angiography can play a vital role in assessing the integrity of relevant vascular structures. Moreover, catheter angiography with embolization can be a most useful nonsurgical adjunct to control the extent of vascular injury.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/25. Bilateral sixth nerve palsy after head trauma.Gaze deficits are not uncommon after head trauma and might be caused by injury to the central nervous system, the peripheral nerve, or the motor unit. Traumatic bilateral sixth cranial nerve palsies are a rare condition and are typically associated with additional intracranial, skull, and cervical spine injuries. We describe a case of a complete bilateral sixth nerve palsy in a 44-year-old male patient with trauma with no intracranial lesion, no associated skull or cervical spine fracture, and no altered level of consciousness. The emergency physician should be aware of the differential diagnosis, initial workup, and injuries associated with a traumatic gaze deficit.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/25. tinnitus in childhood.All of 1,420 children seen for clarification of a hearing disorder or to follow up for known difficulty in hearing were questioned as to whether they experienced tinnitus. The interview was carried out after a hearing test was conducted, which was based on play audiometry or normal pure-tone threshold audiometry, depending on the age of the child. When being interviewed, 102 children reported that tinnitus had appeared or was still present. Seventy-five children (73.5%) demonstrated difficulty in hearing in one or both ears, whereas 27 children (26.5%) had normal hearing in both ears. The most frequently obtained information (29.4%) was the progression of an existing hearing loss. meningitis is an important cause of hearing loss and of tinnitus and could be identified in 20% of our patients. We also considered as a cause of tinnitus skull or brain trauma, acute hearing loss, and stapes surgery. However, the mechanisms of tinnitus development were not immediately clear in a large proportion of the children studied: Problems included central sensory perception (14.7%) and emotional factors (11.8%). No additional information that might lead to an understanding of the hearing loss was available for 14.7% of the patients studied. tinnitus is a frequent symptom in childhood and, because children seldom complain about their tinnitus, such hearing problems that they report must always be taken seriously. The diagnosis should exclude metabolic disturbances, possible damage to the sensory level of the central nervous system, and circulatory disturbances. In addition, the physician should always consider emotional problems and disturbances of perception.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/25. Chronic subdural hematoma presenting as headache and cognitive impairment after minor head trauma.Although relatively uncommon, a chronic subdural hematoma carries a high incidence of morbidity and potential mortality. An aging population combined with an increased usage of anti-platelet and anticoagulation drugs enhances the likelihood that physicians will encounter this condition in routine practice. A heightened index of suspicion, coupled with a thorough clinical and diagnostic examination, is necessary to uncover this sometimes indolent problem. This case study highlights the presentation of an unusual case and discusses the diagnosis, evaluation and treatment of chronic subdural hematomas.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/25. Head trauma.Head trauma is a common and devastating injury. Along with a high mortality rate, the long-term morbidity is consequential for both the individual patient and society. A thorough knowledge of the clinical approach will assist the emergency physician in providing optimal care and helping to minimize secondary brain injury. Using a case-based scenario, the initial management strategies along with rational evidence-based treatments are reviewed.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/25. Difficult airway management.airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult. The most important part of success in the management of a difficult airway is preparation. When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response. The following article will review the principles of airway management with an emphasis upon preparation, strategies for preventing or avoiding difficulties, and recommended technical details that hopefully will encourage the reader to be more prepared and technically skillful in practice.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/25. Post-traumatic migraine: chronic migraine precipitated by minor head or neck trauma.Minor trauma to the head or neck is occasionally followed by severe chronic headaches. We have evaluated 35 adults (27 women, 8 men) with no prior history of headaches, who developed recurrent episodic attacks typical of common or classic migraine following minor head or neck injuries ("post-traumatic migraine"-PTM). The median age of these patients was 38 years (range 17 to 63 years), which is older than the usual age at onset of idiopathic migraine. The trauma was relatively minor: 14 patients experienced head trauma with brief loss of consciousness, 14 patients sustained head trauma without loss of consciousness, and 7 patients had a "whiplash" neck injury with no documented head trauma. Headaches began immediately or within the first few days after the injury. PTM typically recurred several times per week and was often incapacitating. The patients had been unsuccessfully treated by other physicians, and there was a median delay of 4 months (range 1 to 30 months) before the diagnosis of PTM was suspected. The response to prophylactic anti-migraine medication (propranolol or amitriptyline used alone or in combination) was gratifying, with 21 of 30 adequately treated patients (70%) reporting dramatic reduction in the frequency and severity of their headaches. Improvement was noted in 18 of the 23 patients (78%) who were still involved in litigation at the time of treatment. The neurologic literature has placed excessive emphasis on compensation neurosis and psychological factors in the etiology of chronic headaches after minor trauma. physicians must be aware of PTM, as it is both common and treatable.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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