The American journal of emergency medicine
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Case Reports
Is abdomen release really necessary for prone ventilation in acute respiratory distress syndrome?
Prone ventilation for refractory acute respiratory distress syndrome (ARDS) mandates free abdomen by rolls in between chest wall and pelvic bones for better ventilation and control of airway pressure. We observed that, in patients with severe ARDS, prone ventilation with movable free abdomen produced high plateau pressure reduced by applying simple support to abdominal wall. Here, we have proposed a possible hypothesis to explain the paradoxical event in this particular group of patients. ⋯ In patients with severe ARDS in prone position, gravitational pressure transmits through abdominal support, resulting in better chest wall expansion and leading to more oxygenation and opening of the alveoli in ventral lung along with the dorsal lung portion that is usually better ventilated in prone position. There is no clinical trial regarding this particular observation. We suggest randomized trials to prove our observational findings.
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Phenytoin has a narrow therapeutic window, and when managing cases of toxicity, clinicians are very wary of this fact. Typically, if patient presents with symptoms suggestive of phenytoin toxicity, total serum phenytoin is promptly ordered. ⋯ Herein, we describe a case of an elderly male patient who presented with drowsiness, gait changes, and elevated liver enzymes and a normal total serum phenytoin level of 18 ng/dL (normal, 10-20 ng/dL). After taking his albumin level into account, his free phenytoin level was calculated to be 27 ng/dL, and the phenytoin was discontinued leading to resolution of his symptoms as well as a return of his liver function panel values to baseline.
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Computed tomography angiography (CTA) has been applied in imaging studies for the assessment of most abdominal and pelvic injuries in some trauma centers. However, in most institutions, CTA is not routinely performed as part of the computed tomography scan protocol. In this study, we aimed to assess the efficiency of CTA in the evaluation of patients with pelvic fractures. ⋯ In the management of patients with pelvic fractures, CTA provides limited benefits in the evaluation of the active arterial hemorrhage. The additional arterial phase may be helpful for distinguishing between arterial and venous hemorrhage. However, this study showed that subsequent treatment was not changed.
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Catatonia was first described by a German psychiatrist, Karl Kahlbaum, in 1874. It is a behavioral syndrome marked by an inability to move normally, which can occur in the context of many underlying general medical and psychiatric disorders. A wide variety of neurologic, metabolic, drug-induced, and psychiatric causes of catatonia have been reported. ⋯ After extensive emergency department testing, including negative computed tomography head, negative magnetic resonance imaging brain, negative electroencephalogram, and normal laboratory results, the patient was diagnosed with new-onset bipolar disorder with depressive features presenting as catatonia. Recognizing catatonia is important because it may be caused or exacerbated by treatment of the underlying disorder. Failure to institute treatment early in the course of catatonia is associated with a poor prognosis.
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Rescuers that undergo acute ascent without acclimatization can experience acute mountain sickness. Although performing cardiopulmonary resuscitation (CPR) for a short period requires intensive effort at sea level, performing CPR at high altitude is even more exhausting and can endanger the rescuer. Therefore, we conducted a pilot study to compare the quality of resuscitation in health professionals at high altitude (3100 m) and that at sea level. ⋯ The quality of CC rapidly declined at high altitude. At high altitude, the average number of effective CC decreases; and this decrease became significant after continuous CCs had been performed for 1 minute.