Emergency medicine clinics of North America
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Submersion accidents are an important public health problem in this country and worldwide, and they present a special challenge to emergency personnel. Submersion injury affects multiple systems but most notably involves the lungs, where ventilation-perfusion mismatching and intrapulmonary shunting result in hypoxemia, acidosis, and generalized anoxic injury. Resuscitation of the victims of submersion casualties should be directed at restoring respiration, improving oxygenation, correcting acidosis, and treating concomitant problems such as hypothermia, drug and alcohol intoxication, or cervical spinal trauma. With expeditious and proper treatment, most submersion victims have a good prognosis.
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The health problems of diving are due primarily to the breathing of compressed air or other gas mixtures at higher than normal atmospheric pressure. This article focuses on the three main pressure-related syndromes that are collectively known as dysbarism. Emergency physicians should be familiar with the special considerations required in the management of victims of diving casualties.
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The resuscitation of the traumatized patient with multisystem injuries begins on the scene of the incident, continues into the emergency department, and finally includes the surgeon and the operating room. Treatment of the traumatized patient requires a systematic approach to best utilize all facilities and personnel while limiting duplication of service. The patient must go to the facility that best meets his or her needs. ⋯ Hetastarch may turn out to be a valuable addition to the fluid management of these patients. The patient is entitled to one physician who can call the consultants together. In addition, there should be a single physician for the patient who can control the timing of operative intervention as well as coordinate the overall management by the consultants.
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The diagnosis of hypothermia rests solely upon a measured core temperature of 35 degrees C or less; a special thermometer calibrated to record low temperatures should be used whenever hypothermia is suspected. Hospital management of the hypothermic patient consists of definitive rewarming therapy.
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Certain practices and procedures that take place in the emergency department may complicate the subsequent investigation of a death. Recognizing that the emergency physician has a duty to care for the living patient that cannot be compromised, the author focuses on the areas in which emergency department practices may be modified to better meet the need for an accurate and informed determination of the cause of death.