J Emerg Med
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Subcutaneous emphysema of a limb after acute injury is classically associated with gas gangrene. Delayed management can result in amputation and death. Typically caused by a clostridial infection, patients are unwell, with rapidly spreading clinical signs, abnormal laboratory results, and cultures positive. There are reports of widespread subcutaneous emphysema of a limb in well-appearing patients, with blood parameters within normal limits; however, the optimum management of this type of case is unclear. ⋯ Here we present a case series of 4 patients, all with penetrating injuries to the upper limb resulting in widespread subcutaneous emphysema within 24 h of injury. Mean age was 33 years. All were fit and well, with the exception of one with type 1 diabetes, no cardiorespiratory compromise, and no significant derangement of laboratory investigations. X-ray studies showed widespread gas within the soft tissues. All were treated aggressively with immediate surgical fasciotomy of the upper limb, thorough debridement, and washout as required. Gram stains revealed pus cells (polymorphonuclear leucocytes) in all, but organisms in only one case (Gram-positive cocci and bacilli). Prolonged culture grew organisms in all. All patients had a second washout and closure plus 6 weeks of antibiotics. All survived and had fully functioning limbs. Why should an emergency physician be aware of this? We recommend having a low threshold for rapid referral to an appropriate surgical speciality, allowing prompt and radical surgical management of this type of presentation, even in the presence of a well patient.
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Review Case Reports
Emergency Cesarean Section Due to Acute Aortic Dissection Type A (Debakey I) without Marfan Syndrome: A Case Report and Review of the Literature.
Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature. ⋯ This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.
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Lumbar puncture (LP) is a commonly performed procedure in pediatrics. Accurate analysis of cerebrospinal fluid (CSF) profile is essential in diagnosing and managing a variety of infectious and inflammatory conditions involving the brain, meninges, and spinal cord. It can also provide useful diagnostic information in the evaluation of possible subarachnoid hemorrhage and demyelinating syndromes, and aid in the diagnosis and management of pseudotumor cerebri. ⋯ A thorough understanding of anatomic, physiologic, and pathologic considerations regarding performing lumbar puncture and CSF analysis can augment success in diagnosing a variety of potentially serious pediatric conditions.
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Randomized Controlled Trial Comparative Study
Randomized Trial of Bilevel versus Continuous Positive Airway Pressure for Acute Pulmonary Edema.
Studies have shown different clinical outcomes of noninvasive positive pressure ventilation (NPPV) from those of continuous positive airway pressure (CPAP). ⋯ Compared to CPAP to treat APE, BPAP more rapidly improves oxygenation and dyspnea scores, and reduces the need for ICU admission. Further, BPAP does not increase MI rate compared to CPAP.
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The benefits of Tactical Emergency Medical Support (TEMS) elements are providing injury prevention, immediate care of injuries, and medical augmentation of the success of dangerous law enforcement operations. TEMS is recognized by civilian Special Weapons and Tactics (SWAT) and various other law enforcement agencies around the country as a vital addition to such SWAT teams. The integration of specially trained TEMS personnel has become a key component of law enforcement special operations. ⋯ Physician involvement is an essential element of a successful TEMS program. There is a need for more physicians to become involved as TEMS personnel for specialized tactical teams to spread the time commitment and increase their availability to tactical units on a daily basis.