The American journal of emergency medicine
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An 80-year-old man was treated, non-operatively, for a distal esophageal perforation, diagnosed nine days after blunt thoracic trauma. Emergency department diagnosis was impeded by absence of mediastinal air; right chest-wall emphysema was thought to result from associated rib fractures. ⋯ This mode of therapy may be best in comparable elderly patients with esophageal perforation that is overlooked during the initial 24 hours after injury. Possibly, routine barium swallow in all patients with chest-wall emphysema and rib fractures would circumvent missed esophageal rupture after blunt trauma.
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The case of a man who injected turpentine intravenously in an attempt to kill himself is reported. The patient developed immediate pulmonary edema and hypoxia, followed later by cellulitis at the site of injection. Although only one death to date has been attributed to this form of chemical abuse, extensive local reactions, pulmonary involvement, central nervous system depression, and febrile reactions should be anticipated, and such patients should be admitted to the hospital. Patients should be observed for local reactions and myonecrosis around the site of injection, especially as these occur 12-24 hours later.
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An unusual case of a misdirected nasogastric tube is described. An elderly woman was brought to an emergency department following intentional drug overdose. Initially unrecognized errant placement of a large-bore nasogastric tube resulted in tension pneumothorax, pneumonia, and subsequent death. Pertinent medical literature is reviewed, clinical considerations for the elderly patient are discussed, and suggestions for proper nasogastric tube placement are offered.
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Clinical Trial Controlled Clinical Trial
Antibiotic prophylaxis in intraoral wounds.
This study of 100 patients was undertaken to determine the efficacy of penicillin/erythromycin prophylaxis in the management of intraoral lacerations in the pediatric population. Only six patients of the evaluable population developed infections (6.4%). Two of these patients received antibiotic prophylaxis (4%), and the other four were control patients (8%) who developed wound infections (P = 0.41). ⋯ Cross-product ratios for these small sample subgroups indicated that the likelihood of infection for non-prophylactically treated patient wounds of greater than 1 cm length and/or those requiring suturing was two to three times higher than that of patients treated prophylactically. Although no statistical significance could be ascribed to the observed differences of these post hoc categories, benefit from antibiotic prophylaxis may have been quantifiable in a study designed to assess only these major wounds utilizing a large sample size. In general, routine antibiotic prophylaxis appears unwarranted for simple intraoral lacerations in children, although it may be useful when the wounds are large enough to be sutured.
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A case of massive degloving injury of the trunk, with open pelvic fracture, and evisceration of abdominal contents from blunt trauma is presented. The most significant aspect of this case was the transfusion of 173 units of packed cells and 176 units of fresh frozen plasma in the first thirty hours. The patient ultimately recovered and returned to work.