The American journal of emergency medicine
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Comparative Study
Patient satisfaction and diagnostic accuracy with ultrasound by emergency physicians.
In recent years, there has been considerable interest and controversy concerning the performance of ultrasound by emergency physicians (ED Sono), but patient satisfaction with ED Sono has not been well studied. The primary purpose of this investigation was to assess the level of patient satisfaction with ED Sono and to compare satisfaction with ED Sono with ultrasound by the Medical Imaging Department (MI Sono). A secondary objective was to assess the accuracy of ED Sono at our facility. ⋯ Eighteen percent of ultrasounds performed by emergency physicians were indeterminate. Excluding indeterminate scans and scans for which confirmation was not possible, the accuracy of ED Sono was 99.1% (95% Cl, 95.1% to >99.9%). We conclude that during the startup phase of our ED Sono program, patient satisfaction was high, and the error rate was very low.
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Review Case Reports
Subarachnoid hemorrhage following permissive hypercapnia in a patient with severe acute asthma.
In this article, we describe a case of a subarachnoid hemorrhage (SAH) in an acute severe asthma patient following mechanical hypoventilation. A 49-year-old man was admitted to an Intensive Care Unit with an acute exacerbation of asthma. After 3 days of mechanical ventilation (hypercapnia and normoxaemia), it was noted that his right pupil was fixed, dilated, and unreactive to light. ⋯ Since normoxaemic hypercapnia has been associated with absence, or less cerebral edema, we considered additional factors to explain cerebral edema and intracranial hypertension causes. Thus, intrathoracic pressures due to patient's efforts by forcibly exhaling, or during mechanical ventilation, would further increase intracranial pressure by limiting cerebral venous drainage. This case emphasizes the fact that patients with acute severe asthma who have developed profoundly hypercarbic without hypoxia before or during mechanical ventilation, may have raised critical intracranial pressure.
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The Wolff-Parkinson-White syndrome (WPW), estimated to occur in approximately 0.1% to 3% of the general population, is a form of ventricular preexcitation involving an accessory conduction pathway. The definition of WPW relies on the following electrocardiographic features: (1) a PR interval less than 0.12 seconds (2) with a slurring of the initial segment of the QRS complex, known as a delta wave, (3) a QRS complex widening with a total duration greater than 0.12 seconds, and (4) secondary repolarization changes reflected in ST segment-T wave changes that are generally directed opposite (discordant) to the major delta wave and QRS complex changes. The accessory pathway bypasses the atrioventricular (AV) node, creating a direct electrical connection between the atria and ventricles. ⋯ When symptoms do occur they are usually secondary to tachyarrhythmias; the importance of recognizing this syndrome is that these patients may be at risk to develop a variety of supraventricular tachyarrhythmias which cause disabling symptoms and, in the extreme, sudden cardiac death. The tachyarrhythmias encountered in the WPW patient include paroxysmal supraventricular tachycardia (both the narrow QRS and wide QRS complex varieties), atrial fibrillation, atrial flutter, and ventricular fibrillation. Diagnostic and urgent, initial therapeutic issues based on initial electrocardiographic information are presented via 5 illustrative cases.
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A 31-year-old woman presented with complaints of increasingly severe right lower quadrant discomfort that had occurred for several days each month over the course of the previous 6 months. A tender mass of the abdominal wall was palpated on physical examination, and subsequent ultrasonography and magnetic resonance imaging disclosed a discrete mass of the body of the right rectus abdominis muscle which was confirmed as endometrial tissue on biopsy. Rectus abdominis endometrioma is a relatively rare cause of abdominal pain which may mimic an acute abdomen. Clinical clues to the diagnosis include previous uterine or gynecological surgery/invasive procedure (with preservation of ovarian function), cyclical nature of the discomfort, and the presence of a palpable mass with or without associated skin color changes.
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Pneumomediastinum, pneumothorax, and subcutaneous emphysema can occur occasionally after a surgical procedure. Facial swelling is a common complication of dental management. ⋯ We present a case with subcutaneous emphysema of the upper chest, neck, chin, and pneumomediastinum after a tooth extraction and discuss the possible mechanism of subcutaneous emphysema. To prevent these complications during dental procedures, dental hand pieces that have air coolant and turbines that exhaust air in the surgical field should not be used.