The American journal of emergency medicine
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Case Reports
Transdiaphragmatic repositioning of the heart in the setting of emergency laparotomy after blunt trauma.
Cardiac luxation after blunt trauma is a rare condition that carries a high mortality rate. We report a case of a left pericardial rupture with partial dislocation of the heart into the left pleural cavity and cardiac strangulation in a polytraumatized patient after a severe motor vehicle accident. This case is of special interest because the patient not only had cardiovascular compromise but was also actually in cardiac arrest and being resuscitated when an emergency repositioning of the heart through the diaphragm in the setting of damage control laparotomy restored circulation. This report stresses the need for a high index of suspicion for accurate early diagnosis of pericardial rupture.
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Myxedema coma is the most lethal manifestation of hypothyroidism. It is a true medical emergency and can result in profound hemodynamic instability and airway compromise. Myxedema coma currently remains a diagnostic challenge due to the rarity of cases seen today, and failure to promptly initiate therapy with replacement thyroid hormone can be fatal. ⋯ We describe a case of an unidentified woman who presented to the ED with myxedema coma requiring urgent endotracheal intubation and was found to have extensive posterior pharyngeal angioedema inconsistent with her relatively benign external examination. This case highlights the typical features of myxedema coma and discusses our necessity for a rescue device in definitive endotracheal tube placement. Emergency physicians should anticipate a potentially difficult airway in all myxedema coma patients regardless of the degree of external facial edema present.
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Editorial Comment
Ethics, equipoise, and evidence: when should investigators decide to not test their hypothesis.
In an excellent investigation of endotracheal tube cuff pressure assessment, "Endotracheal Tube Cuff Pressures in Patients Intubated Prior to Transport," Chapman et al measured endotracheal tube cuff pressure in patients who arrive at their emergency department after being intubated in the field. This, the first published American study of this type, presents clear and convincing evidence that patients who undergo endotracheal intubation before transport have endotracheal tube cuff pressures that exceed safe limits. ⋯ Our hope is that readers will acknowledge the study of Chapman et al as a strong piece of evidence indicating that patients who undergo endotracheal intubation without measurement of endotracheal tube cuff pressure very likely have a pressure that exceeds the safe range. We hope this study, in conjunction with the other available evidence, will prompt readers to adopt measurement of endotracheal tube cuff pressure as a routine.
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The advantage of vasopressin over epinephrine in the treatment of cardiac arrest (CA) is still being debated, and it is not clear whether a high dose of vasopressin is beneficial or detrimental during or after cardiopulmonary resuscitation (CPR) in a rat model of CA. In this study, asphyxial CA was induced in 40 male Sprague-Dawley rats. After 10 minutes of asphyxia, CPR was initiated; and the effects of different doses of vasopressin (low dose, 0.4 U/kg; medium dose, 0.8 U/kg; and high dose, 2.4 U/kg; intravenous; n = 10 in each group) and a saline control (isotonic sodium chloride solution, 1 mL, intravenous) were compared. ⋯ However, the heart rate was lower in the high-dose vasopressin group than in the low- and medium-dose groups. These findings indicate that different doses of vasopressin result in a similar outcome of CPR, with no additional benefits afforded by a high dose of vasopressin during or after CPR, in a rat model of asphyxial CA. The mechanism and physiologic significance of the relative bradycardia that occurred in the high-dose vasopressin group are currently unknown and require further investigation.
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Case Reports
Acute appendicitis presenting with Klebsiella pneumoniae septicemia due to bacterial translocation.
Bacterial translocation (BT) is defined as the passage of viable bacteria from the gastrointestinal tract, across the intestinal wall, to the mesenteric lymph nodes or other extranodal sites and bloodstream. It has been shown in both animal and human studies and has been implicated as a source of sepsis in susceptible patients. ⋯ Thorough clinical investigation ruled out other sources of infection. Emergency physicians should be aware that septicemia may be the dominant presentation of acute appendicitis, due to dissemination of the infection into the bloodstream, secondary to bacterial translocation.