J Emerg Med
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Cricothyrostomy is the procedure of choice for emergency airway control when nasotracheal and endotracheal intubation are not possible or contraindicated. A vertical skin incision followed by a horizontal incision in the cricothyroid membrane are used. A number 6 tracheostomy tube should be used due to the anatomic size of the cricothyroid space. Using this technique, complications are rare.
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Controversial therapeutic issues in patients with caustic ingestions concern the reliability of symptoms and signs in predicting esophageal injury, the appropriate use of endoscopy in evaluating esophageal damage, and the use of steroids in preventing late strictures. The conclusions of this review are: The majority of pediatric caustic ingestions involve a "lick and taste" whereas adolescents and adults often ingest substantial quantities. ⋯ Endoscopy should be an elective rather than emergency procedure and should be undertaken in all symptomatic patients, and in asymptomatic patients when history indicates substantial ingestion. Steroid therapy should be considered only for patients who have deep or circumferential esophageal burns.
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Percutaneous central venous catheterization provides access for volume replacement and hemodynamic monitoring. This study reviewed 119 percutaneous central venous catheterizations in 112 patients over a 12-month period. All catheters were placed by emergency department (ED) physicians or housestaff under their direct guidance. ⋯ Postoperatively, five (26%) of these were converted to pulmonary artery catheters. Central venous catheters can be placed in patients percutaneously in the emergency department with minimal morbidity. They provide initial access to the central circulation for resuscitation and subsequently can be converted to pulmonary artery catheters for hemodynamic monitoring.
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The beneficial hemodynamic effects of sodium bicarbonate as treatment for tricyclic antidepressant poisoning were investigated in an animal model. Seven adult dogs (17.5 to 20 kg) were poisoned by an intravenous infusion of amitriptyline. Toxicity was defined as a doubling of the initial QRS width. ⋯ All dysrhythmias ceased within one minute of administration of sodium bicarbonate. An increase in mean blood pressure (P less than .05) and serum pH (P less than .05) and a decrease in mean QRS width (P less than .05) occurred following administration of sodium bicarbonate. The maintenance of toxicity for 30 minutes suggests that this model can be used for future studies of tricyclic antidepressant poisoning.
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Lumbar puncture has been in widespread clinical use for nearly a century. It is used in emergency medicine primarily as a tool for the diagnosis of meningoencephalitis and subarachnoid hemorrhage. The development of computed tomography has changed the position that lumbar puncture has held in the diagnostic sequence of a number of clinical entities. ⋯ Meningitis has been found to follow lumbar puncture in children with bacteremia. The lumbar puncture is a useful test for providing information regarding the cellular, chemical, and microbiologic composition of the CSF. Fluid obtained should be evaluated for cell count, Gram's stain, bacterial culture, glucose and protein levels, and other tests as clinically indicated.