BMJ case reports
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Case Reports
Intraoperative hypercarbia and massive surgical emphysema secondary to transanal endoscopic microsurgery (TEMS).
We describe a case where full-thickness excision of a rectal lesion caused massive surgical emphysema and subsequent hypercarbia with associated difficulties with ventilation. This unique case highlights the risks of respiratory failure with extraperitoneal insufflation as in this case and as more commonly with intraperitoneal insufflation. ⋯ We reviewed the literature in order to understand the case and to highlight factors that should minimise any adverse sequelae. In the presence of ventilatory difficulties secondary to postoperative surgical emphysema, whether via extraperitoneal insufflation as described here or with intraperitoneal insufflation (as in laparoscopy), consider decreasing gas pressures, expediting the procedure, delaying extubation and prolonged close monitoring in recovery with possible admission to a high dependency unit (HDU) or intensive care unit (ICU).
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This is the remarkable story of survival against all the odds. A passenger had a myocardial infarction complicated by a witnessed cardiac arrest while on a commercial flight through some of the most remote airspace on the planet. ⋯ Passengers and crew worked effectively together, under the guidance of a physician, to provide critical care to the patient while the flight diverted so he could be transferred to an emergency hospital in Beijing for eventual thrombolysis and postresuscitation care. He made a rapid and full recovery to be discharged from hospital, neurologically intact, 10 days later.
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Case Reports
Spontaneous bladder rupture of a urinary bladder with non-muscle invasive bladder cancer.
We describe the case of a 65-year-old man who developed spontaneous bladder rupture after picking up his suitcase from a squatting position. He was known to have non-muscle invasive bladder cancer (NMIBC), managed previously with transurethral resections and intravesical chemotherapy. ⋯ Management was initially conservative, with insertion of urethral catheter, intravenous antibiotics and fluid resuscitation. Follow-up CT scan showed resolution of the urinoma with the patient making a full recovery after 3 weeks.
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Chronic alcoholism is a frequently unrecognised cause of ketoacidosis. Most patients with alcoholic ketoacidosis present with normal or low glucose, but this condition can present with hyperglycaemia. This can lead to misdiagnosis of diabetes ketoacidosis and, therefore, inappropriate treatment with insulin. ⋯ On review of her history, she was found to have three similar episodes over the past 12 months. Alcoholic ketoacidosis can present with hyperglycaemia due to relative deficiency of insulin and relative surplus in counter-regulatory stress hormones including glucagon. Awareness of the syndrome with a detailed history helps to differentiate alcohol ketoacidosis from diabetes ketoacidosis and prevent iatrogenic hypoglycaemia.
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Case Reports
Pulmonary intravascular talcosis mimicking miliary tuberculosis in an intravenous drug addict.
Pulmonary foreign body granulomatosis following intravenous administration of medications meant for oral use among drug addicts has been occasionally reported. This condition is often misdiagnosed because of its rarity, but rather due to its similarity to other pulmonary diseases that are more common. ⋯ The condition was caused by intravenous administration of crushed tablets of diphenhydramine, but miliary tuberculosis was misdiagnosed on patient's demographical, clinical and radiological grounds and a decision to start treatment with four first-line antituberculosis drugs followed. The current report refers to the importance of considering rare causes of pulmonary disseminations with attempts to identify the causative agent and warns against the use of antituberculosis treatment without confirmation of microbiological diagnosis of tuberculosis.