Emergency medicine practice
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Identifying and correcting sodium abnormalities is critical, since suboptimal management potentially leads to substantial morbidity and mortality. Manifestations of hyponatremia, which is one of the more common electrolyte abnormalities in clinical medicine, depend on multiple factors, including the chronicity of the symptoms, the absolute level of sodium, and the patient's overall health. ⋯ Acute symptomatic hypernatremia should be corrected rapidly, while chronic hypernatremia is generally corrected more slowly due to the risks of brain edema during treatment. Special circumstances do exist in sodium management, and every patient's presentation should be evaluated in clinical context.
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With over 1.7 million people in the United States seeking medical attention for head injury each year, emergency clinicians are challenged daily to screen quickly for the small subset of patients who harbor a potentially lethal intracranial lesion while minimizing excessive cost, unnecessary diagnostic testing, radiation exposure, and admissions. Whether working at a small, rural hospital or a large inner-city public hospital, emergency clinicians play a critical role in the diagnosis and management of mild traumatic brain injury. This review assesses the burgeoning research in the field and reviews current clinical guidelines and decision rules on mild traumatic brain injury, addressing the concept of serial examinations to identify clinically significant intracranial injury, the approach to pediatric and elderly patients, and the management of patients who are on anticoagulants or antiplatelet agents or have bleeding disorders. The evidence on sports-related concussion and postconcussive syndrome is reviewed, and tools for assessments and discharge are included.
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Review Case Reports
Advances in diagnosis and management of hypokalemic and hyperkalemic emergencies.
With up to 56% of individuals taking diuretics likely to develop hypokalemia, and comorbid disease and many other types of medications having the potential to induce hyperkalemia, potassium abnormalities are some of the most commonly seen electrolyte abnormalities in the emergency department (ED). Unless recognized and treated appropriately, they can also be some of the most deadly. ⋯ Recognition and treatment of life-threatening dysrhythmias in hypokalemia and hyperkalemia are key to managing these potassium abnormalities. Electrocardiogram (ECG) findings, treatment algorithms, and controversies on treating potassium abnormalities in the ED are discussed, with recommendations on criteria for disposition.
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A number of concerns have been raised regarding the advisability of the classic principles of aggressive crystalloid resuscitation in traumatic hemorrhagic shock. This issue reviews the advances that have led to a shift in the emergency department (ED) protocols in resuscitation from shock state, including recent literature regarding the new paradigm for the treatment of traumatic hemorrhagic shock, which is most generally known as damage control resuscitation (DCR). ⋯ The primary conclusions include the administration of tranexamic acid (TXA) for all patients with uncontrolled hemorrhage (Class I), the implementation of a massive transfusion protocol (MTP) with fixed blood product ratios (Class II), avoidance of large-volume crystalloid resuscitation (Class III), and appropriate usage of permissive hypotension (Class III). The choice of fluid for initial resuscitation has not been shown to affect outcomes in trauma (Class I).
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Appendicitis is the most common cause of acute abdominal pain requiring surgical treatment in persons under 50 years of age, with a peak incidence in the second and third decades. Women have a greater risk of misdiagnosis and a higher negative appendectomy rate. Atypical presentations of appendicitis are commonly misdiagnosed, resulting in increased morbidity, mortality, and potential litigation. ⋯ Patients presenting with possible appendicitis should be risk stratified based on history, physical examination, and laboratory data. An elevated white blood cell (WBC) count alone (> 10,000 cells/mm3) offers poor diagnostic utility; however, combining WBC count > 10 and C-reactive protein (CRP) level > 8 achieves notable predictive power in the diagnosis of acute appendicitis. Imaging studies play a vital role in diagnosis, particularly in equivocal presentations.