1/27. Expeditious diagnosis of primary prosthetic valve failure.Primary prosthetic valve failure is a catastrophic complication of prosthetic valves. Expeditious diagnosis of this complication is crucial because survival time is minutes to hours after valvular dysfunction. The only life-saving therapy for primary prosthetic valve failure is immediate surgical intervention for valve replacement. Because primary prosthetic valve failure rarely occurs, most physicians do not have experience with such patients and appropriate diagnosis and management may be delayed. A case is presented of a patient with primary prosthetic valve failure. This case illustrates how rapidly such a patient can deteriorate. This report discusses how recognition of key findings on history, physical examination, and plain chest radiography can lead to a rapid diagnosis.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/27. Successful resuscitation of a verapamil-intoxicated patient with percutaneous cardiopulmonary bypass.OBJECTIVE: To describe our experience with the use of percutaneous cardiopulmonary bypass as a therapy for cardiac arrest in an adult patient intoxicated with verapamil. DESIGN: Case report. SETTING: Emergency department of a university hospital. PATIENT: A patient with cardiac arrest after severe verapamil intoxication. INTERVENTIONS: Percutaneous cardiopulmonary bypass and theophylline therapy. CASE REPORT: A 41-yr-old white male had taken 4800-6400 mg of verapamil in a suicide attempt. On arrival of the ambulance physician, the patient was conscious with weak palpable pulses and was transported to a nearby hospital. The patient developed a pulseless electrical activity, and cardiopulmonary resuscitation was started. Despite all advanced life support efforts, the patient remained in cardiac arrest. Therefore, he was transferred under ongoing cardiopulmonary resuscitation to our department, where percutaneous cardiopulmonary bypass was initiated immediately (2.5 hrs after cardiac arrest). The first verapamil serum concentration obtained at admittance to our institution was 630 ng/mL. After several ineffective intravenous epinephrine applications, the administration of 0.48 g of theophylline as an intravenous bolus 6 hrs and 18 mins after cardiac arrest led to the return of spontaneous circulation. The patient remained stable and was transferred to an intensive care unit the same day. He woke up on the 12th day and was extubated on the 18th day. After transfer to a neuropsychiatric rehabilitation hospital, he recovered totally. CONCLUSION: In patients with cardiac arrest attributable to massive verapamil overdose, percutaneous extracorporeal cardiopulmonary bypass can provide adequate tissue perfusion and sufficient cerebral oxygen supply until the drug level is reduced and restoration of spontaneous circulation can be achieved.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/27. Toxicity of over-the-counter cough and cold medications.Over-the-counter (OTC) cough and cold medications are marketed widely for relief of common cold symptoms, and yet studies have failed to demonstrate a benefit of these medications for young children. In addition, OTC medications can be associated with significant morbidity and even mortality in both acute overdoses and when administered in correct doses for chronic periods of time. physicians often do not inquire about OTC medication use, and parents (or other caregivers) often do not perceive OTCs as medications. We present 3 cases of adverse outcomes over a 13-month period-including 1 death-as a result of OTC cough and cold medication use. We explore the toxicities of OTC cough and cold medications, discuss mechanisms of dosing errors, and suggest why physicians should be more vigilant in specifically inquiring about OTCs when evaluating an ill child.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/27. Iatrogenic cardiopulmonary arrest during pediatric sedation with meperidine, promethazine, and chlorpromazine.The pediatric sedative combination of meperidine, promethazine, and chlorpromazine (MPC) has been widely used for more than 40 years. Despite its relatively poor efficacy and questionable safety profile, many emergency departments (EDs) continue to stock specially formulated mixtures of these three agents. We report a case of iatrogenic cardiac arrest in a 2-month-old infant in whom a consulting resident administered too much MPC (10 times the expected dose) by the wrong route (intravenous instead of intramuscular). The child was successfully resuscitated with no apparent neurologic deficit. Subsequently, we have removed MPC entirely from our ED and instituted a policy restricting ED procedural sedation privileges to emergency physicians. We urge other EDs to do likewise.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/27. Cardiopulmonary arrest induced by anaphylactoid reaction with contrast media.Anaphylactoid reactions to iodinated contrast media can cause life-threatening events and even death. A 44-year-old woman presented with cardiopulmonary arrest (CPA) immediately following the administration of nonionic iodinated contrast media for an intravenous pyelography. Her cardiac rhythm during CPA was asystole. She was successfully resuscitated by the radiologists supported by paged emergency physicians using the prompt intravenous administration of 1 mg of epinephrine. Neither laryngeal edema nor bronchial spasm was observed during the course of treatment, and she was discharged on the 4th day without any complications. The patient did not have a history of allergy, but had experienced a myocardial infarction and aortitis. She had undergone 11 angiographies and had been taking a beta-adrenergic receptor antagonist. Planned emergency medical backup is advisable to ensure resuscitation in the event of an anaphylactoid reaction to the use of contrast media in-hospital settings.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/27. Fatal angioedema associated with lisinopril.OBJECTIVE: To report a case of fatal angioedema associated with the use of lisinopril, a long-acting angiotensin-converting enzyme (ACE) inhibitor. DATA SOURCES: case reports, review articles, short reports, and pertinent information from the patient's medical record. DATA EXTRACTION: Data was collected from contemporary medical journals and reviewed by both authors. DATA SYNTHESIS: angioedema associated with ACE inhibitors (captopril and enalapril) is well documented in the literature. With increased prescribing of newer, longer-acting agents, this potentially lethal adverse reaction is of even greater concern. Because angioedema associated with ACE inhibitors is a class-related event, the number of reported cases would be expected to increase with increasing numbers of prescriptions written for these drugs. This report, describing a patient who developed angioedema following therapy with lisinopril, illustrates the severity of this adverse reaction. PATIENT: A 66-year-old man presented to the emergency room complaining of increased swelling of the back of his throat and difficulty breathing. Despite treatment with epinephrine, antihistamines, and corticosteroids, the patient's condition progressed from that of severe laryngeal edema to total laryngospasm and complete airway obstruction. Emergency measures to intubate the patient were complicated by severe swelling of his neck and oropharynx, forcing the physician to perform a grossly traumatic tracheotomy. The difficulty encountered during intubation deprived the patient of oxygen for a significant amount of time, precipitating cardiopulmonary arrest. The anoxic episode resulted in hypoxic, ischemic encephalopathy and, ultimately, death. CONCLUSIONS: angioedema is a serious, potentially life-threatening adverse effect associated with the use of ACE inhibitors. Clinicians need to be aware of this effect when prescribing ACE inhibitors to treat hypertension and congestive heart failure, and when assessing patients presenting to the emergency room with complaints of tongue or pharyngeal swelling. patients should be instructed to report immediately to an emergency room for medical attention if they experience any unexplained shortness of breath or swelling of the throat or tongue.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/27. Remote critical care consultation: telehealth projection of clinical specialty expertise.Remote critical care consultations have been employed between the Naval Hospital in guam and the Tripler Army Medical Center in hawaii, a distance of 5300 km. During a 10-week study period there were physician-physician daily consultation rounds for patients in the intensive care unit at the Naval Hospital. Physiological data, video-images and sound were transmitted via a 768 kbit/s frame relay connection, albeit with a 1-3 s delay. During the study there were 87 consultations concerning 25 patients. Preliminary results showed that a broad range of critical care patients could be managed effectively through daily remote critical care consultation. Broader implementation of this strategy may represent a method of making critical care expertise available to front-line military health-care facilities and to remote civilian facilities with limited critical care expertise.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
8/27. Fatal hypermagnesemia caused by an Epsom salt enema: a case illustration.The authors describe a case of fatal hypermagnesemia caused by an Epsom salt enema. A 7-year-old male presented with cardiac arrest and was found to have a serum magnesium level of 41.2 mg/dL (33.9 mEq/L) after having received an Epsom salt enema earlier that day. The medical history of Epsom salt, the common causes and symptoms of hypermagnesemia, and the treatment of hypermagnesemia are reviewed. The easy availability of magnesium, the subtle initial symptoms of hypermagnesemia, and the need for education about the toxicity of magnesium should be of interest to physicians.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
9/27. Thoracic lavage in accidental hypothermia with cardiac arrest--report of a case and review of the literature.BACKGROUND: Accidental hypothermia resulting in cardiac arrest poses numerous therapeutic challenges. cardiopulmonary bypass (CPB) should be used if feasible since it optimally provides both central rewarming and circulatory support. However, this modality may not be available or is contraindicated in certain cases. Thoracic lavage (TL) provides satisfactory heat transfer and may be performed by a variety of physicians. This paper presents the physiological rationale, technique, and role for TL in accidental hypothermia with cardiac arrest. methods: A patient with hypothermic cardiac arrest, treated by the author using TL, serves as the basis for this report. A search of the English language literature using pubmed (National Library of medicine, Bethesda, maryland) was conducted from 1966 to 2003 and 13 additional patients were identified. Demographic information, lavage method, rewarming rate, complications, and neurological outcome were analysed. RESULTS: There were numerous causes for hypothermia, with drug and alcohol intoxication being the most common (n = 4; 28.6%). Patient age ranged from 8 to 72 years (median = 36 years). Mean core temperature was 24.5 /-0.60 degrees C. Most patients were without blood pressure or pulse upon presentation to the Emergency Department and the predominant cardiac rhythm was ventricular fibrillation (VF) (n = 9; 64.3%). Thoracic lavage was accomplished by thoracotomy in seven patients and tube thoracotomy in the remaining seven. Median rewarming rate was 2.95 degrees C/h. Median time until sinus rhythm was restored was 120 min. Median length of hospital stay was 2 weeks. Four (28.6%) patients died. Complications were seen in 12 (85.7%) patients. Among survivors, neurological outcome was normal in 8 (80%) while two were left with residual impairments. CONCLUSIONS: patients presenting in cardiac arrest from accidental hypothermia may be rewarmed effectively using TL. Among survivors, normal neurological recovery is seen. Thoracic lavage should be strongly considered for these patients if CPB is not available or contraindicated.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/27. Catastrophic presentation of infant botulism may obscure or delay diagnosis.Three infants with infant botulism are presented to illustrate how atypical, early, and severe features may obscure or delay diagnosis. Two boys aged 6 weeks and 20 days, respectively, presented with rapid deterioration after brief periods of poor feeding, one with an apparent life-threatening event at home and the other with a full cardiopulmonary arrest. Initial abnormal laboratory findings of coagulopathy suggested sepsis in the first infant. In the second infant, severe acidosis and hypoglycemia suggested an underlying metabolic disorder. A third infant, aged 1 month, was hospitalized originally with an admitting diagnosis of "pharyngitis" resulting from his inability to take adequate feedings. He received intravenous fluids and antibiotics. One week later he suffered a respiratory arrest. Laboratory findings of severe hyponatremia and acidosis at the time of his arrest suggested a metabolic etiology. Even retrospectively, none of these infants had the typical initial complaint of constipation, and none were noted to have ptosis or facial weakness before catastrophic collapse. However, in each case, the parent had initially brought the child to the physician for "poor feeding" or "poor suck," which was not recognized by medical personnel as a result of bulbar weakness. Ultimately, all 3 infants were found to have infant botulism. All 3 had received antibiotics before catastrophic collapse, possibly contributing to the rapidity of the deterioration. Each recovered, although the delay in diagnosis made them ineligible for treatment with botulism immunoglobulin.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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