1/10. Iatrogenic lesions of the colon and rectum.Our ability to document a number of examples of iatrogenic lesions of the colon and rectum in three general hospitals confirms the multiplicity of these lesions as presented in the literature. It appears that the careful surgeon and his associates would well heed the old admonition known as Murphy's law, that "Anything that can go wrong will go wrong." In the daily practice of the general surgeon and proctologist, it is apparent that gentleness in approaching any anal-rectal examination for either diagnostic or therapeutic purposes is mandatory. The insertion of any foreign object, be it an examining finger, a thermometer, enema tip, or proctoscope, may subject the patient to an inadvertent injury of significant proportion. The dangers inherent in the evaluation and treatment of patients with recognized disease processes is significantly greater than that associated with routine and screening examinations. morbidity and mortality have been shown to be associated with the barium enema as well as with the barium enema as well as with some of the newer radiologic procedures such as mesenteric angiography. The use of tap water for enemas has produced morbidity both from thermal injuries and from electrolyte depletion. Antibiotics and chemotherapeutic drugs frequently result in colon and rectal disease, and therapeutic procedures directed at organs adjacent to the colon and rectum have resulted in a number of iatrogenic lesions. This reviews confirms reports of others that iatrogenic lesions of the colon and rectum are not solely due to the physician's inexperience, as significant numbers of these lesions were the result of the diagnostic or therapeutic efforts of men of considerable experience and skill. Advanced age of the patient and diseases leading to changes in the character of the bowel wall frequently were factors in the production of these lesions. A poorly prepared bowel has led to increased morbidity and mortality associated with iatrogenic perforations. The early recognition of these lesions and prompt medical and surgical management diminishes both the morbidity and mortality associated with such injuries.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/10. Massive hemoperitoneum due to rupture of a retroperitoneal varix.Intra-abdominal hemorrhage from ruptured varices is an unusual, life-threatening complication of portal hypertension. We present the case of a 58-year-old man with alcoholic cirrhosis who presented with increasing abdominal girth, hypovolemic shock, and profound anemia due to rupture of a retroperitoneal varix into the peritoneal cavity. The clinical presentation of this rare problem is remarkably consistent among published reports. Early recognition may help the treating physician reduce the likelihood of a catastrophic outcome.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/10. Recurrent haemoperitoneum in a mild von Willebrand's disease combined with a storage pool deficit.Haemoperitoneum secondary to haemorrhagic corpus luteum has been described in severe bleeding disorders such as afibrinogenaemia, type 3 von Willebrand's disease and patients under oral anticoagulation. We have studied one patient who presented three episodes of severe bleeding at ovulation, requiring surgery twice, with the diagnosis of mild von Willebrand's disease and mild storage pool deficiency. Mild von Willebrand's disease (associated with other thrombopathies or coagulopathies) should be considered in this pathology, although physicians would prefer to find a severe haemorrhagic disorder as the underlying condition in these cases.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/10. Posterior urethral valves presenting as abdominal distension and undifferentiated shock in a neonate: the role of screening emergency physician-directed bedside ultrasound.We present a case of shock in a 7-week-old neonate with obstructive uropathy secondary to posterior urethral valves (PUV). The antenatal ultrasound and the 2-week maintenance visit were unremarkable. A screening emergency physician directed bedside ultrasound (SEPUS) served to rapidly establish the diagnosis, initiate appropriate management, and facilitate early relief of urinary obstruction. We discuss the potential role of SEPUS in a critically ill neonate and briefly review the management of PUV.- - - - - - - - - - ranking = 5keywords = physician (Clic here for more details about this article) |
5/10. Treatment strategies in shock: use of oxygen transport measurements.shock has traditionally been categorized according to its cause. shock can result from hemorrhage, primary cardiac failure, central nervous system failure, trauma, or sepsis. Therapeutic principles have been developed for each etiologic type. End points for such therapy have included optimization of pulmonary capillary wedge pressure, cardiac output, blood pressure, and urine output. Recent investigators agree that the common denominator in each of the shock syndromes is a reduction in the amount of oxygen consumed by the cell. The logical therapeutic approach would be to increase oxygen delivery to support the increased metabolic demand of the cells. The end point of resuscitation should be optimization of oxygen delivery and oxygen consumption. These variables are easily calculated by using data obtained from pulmonary artery catheter and laboratory measurements. The physician or nurse caring for critical ill patients should have a thorough understanding of the rationale for the use of oxygen transport calculations and the methods of manipulating oxygen delivery. A simple explanation of these principles including the importance of hemoglobin, cardiac index, and percent saturation of hemoglobin and suggested treatment strategies are presented.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/10. Tension hydrothorax and shock in a patient with a malignant pleural effusion.A patient presented to the emergency department with a malignant pleural effusion associated with shortness of breath, and radiographic evidence of mediastinal shift and hypotension. Tube thoracostomy yielded serosanguinous pleural fluid under pressure and after 1 liter of fluid was drained, the patient's hemodynamic status stabilized. The entity of tension hydrothorax is rare but may be life threatening. The treatment should consist of prompt drainage and efforts to prevent recurrence. As physicians become more adept at prolonging the lives of patients with cancer, tension hydrothorax may become more common.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/10. An unusual cause of abdominal pain and shock in pregnancy: case report and review of the literature.A near fatal case of spontaneous uterine rupture resulting from placenta percreta is presented. placenta accreta refers to all conditions in which placental villi attach to, invade, or penetrate the myometrium. Placenta percreta is the most extreme form of morbid placental attachment and is said to exist when the uterine wall is completely breached by invading placental villi. Although uncommon, placenta percreta is an important entity of which the emergency physician should be aware because of its propensity to cause uterine rupture and catastrophic bleeding. This article reviews the pathophysiology, presentation, diagnosis, and emergency department management of placenta accreta, increta, and percreta.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/10. MAST: medical antishock trousers.MAST are a simple, safe and sound device with applicability in all shock states; they provide a number of benefits to the hypotensive patient. The main benefits seem to be autotransfusion of peripherally pooled blood originating from the MAST encased areas, increase in peripheral vascular resistance, external tamponade of bleeding vessels and an aid to stabilization of fractured bones of the pelvis and lower extremities. Because an area of hypoperfusion can lead to complications, the pathophysiologic effects of MAST must be understood. The greatest complications occur when MAST are too rapidly removed. They must be removed in an appropriate place by trained physicians under controlled conditions. The key is to deflate the MAST over a prolonged period of time using a gradual release of external pressure. Volume status and acid-base balance must be carefully monitored. In the last few years MAST have had an ever expanding role in both the pre-hospital and hospital phases of care of the critically ill and injured patients. All physicians involved in the care of these patients must be familiar with this device. Applied and removed properly, MAST will sustain blood pressure and save lives.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
9/10. subarachnoid hemorrhage: an unusual presentation of shock.A 42-year-old woman became profoundly hypotensive shortly after arriving at our emergency medical center after a seizure. The patient's blood pressure did not respond to aggressive fluid resuscitation, administration of inotropic agents, vasopressors, or corticosteroids. After a thorough search for the cause of shock, she was found to have a subarachnoid hemorrhage (SAH). hypotension is a rare occurrence in SAH. Several mechanisms of SAH are reviewed in this report and are invoked to explain this patient's lack of response to the standard therapies for hypotension. Emergency physicians should consider SAH in the differential diagnosis of refractory shock in patients who present with neurologic abnormalities.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/10. Transient erythroblastopenia of childhood presenting with shock and metabolic acidosis.Transient erythroblastopenia of childhood is usually a benign, self-limiting underproduction of red blood cells that often goes undetected clinically. The patient presented here, however, required crystalloid boluses and red blood cell transfusion for treatment of shock and metabolic acidosis in the emergency department. The emergency physician must be alert to the patient presenting with severe anemia and procure extra pretransfusion blood samples for anemia studies when transfusion appears imminent. The need for red blood cell transfusion in such a patient must be expeditiously recognized and, when the need exists, transfusions should be started as quickly as possible.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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