Altered mental status and nonconvulsive status epilepticus.
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Ammonia↗
Biomedical subjects
A Jagoda
Publications and source records attributed to A Jagoda.
Nonconvulsive seizures.
A significant percentage of seizures are not motor events. These seizures can be misdiagnosed easily if a seizure disorder is not considered in the differential diagnosis. Nonconvulsive seizures can be psychic, somatosensory, or autonomic in their clinical presentation and have the potential to generalize into convulsive events. It is estimated that 25% of all cases of status epilepticus are nonconvulsive, with altered mental status being the primary clinical manifestation.
Anticonvulsants↗
Psychogenic convulsive seizures.
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Diagnosis, Differential↗
Refractory status epilepticus in adults.
The management of status epilepticus has improved over the past 20 years, resulting in a substantial decrease in the associated morbidity and mortality. Patients who have seizures that are refractory to initial pharmacologic interventions tend to have significant underlying toxic, metabolic, structural, or infectious disorders, and therefore management of refractory status epilepticus must focus on stabilization and on identification and correction of seizure etiology. Regardless of etiology, the faster the seizures are brought under control, the better the prognosis. Risk of central nervous system injury increases after 30 minutes of seizure activity, and therefore efforts should focus on controlling the abnormal electrical discharges at the earliest time possible, preferably within one hour. Benzodiazepines, phenytoin, and phenobarbital remain the most commonly used first- and second-line anticonvulsants, have proven effective in cases of status epilepticus, and should be administered within the first 45 minutes of management. For refractory status epilepticus, pentobarbital anesthesia is evolving as an effective and recommended treatment modality and should be instituted immediately after phenytoin and phenobarbital loading. The role of other anticonvulsants remains to be investigated in controlled clinical trials.
Anticonvulsants↗
Prehospital care and the military.
Significant evolution has occurred in prehospital care over the past decade. Civilian emergency medical service (EMS) systems have become progressively sophisticated. Military systems have tended to maintain a wartime philosophy toward prehospital care, and thus its peacetime ambulance service, at times, is not prepared to provide the same standard of care given by the civilian community. This article reviews the current status of civilian and military EMS and attempts to put in perspective the directions that the military could go to improve on the prehospital care it provides.
Emergency Medical Services↗
Role of the independent duty corpsman on the USNS Comfort (T-AH 20): the Operation Desert Shield/Desert Storm experience.
Independent duty corpsmen (IDCs) have a significant role in providing health care on the USNS Comfort (T-AH 20). The IDCs are responsible for staffing sick call, emergency response teams, and resuscitation/stabilization teams. IDCs are trained in advanced patient care and in medical administrative and logistical duties. During peacetime, their function often focuses on primary care to the decrement of skills necessary to perform in medical emergencies. The Operation Desert Shield/Desert Storm mobilization has emphasized the need for Navy medicine to continue its support of IDC training so that they are kept in a state of preparedness to competently deliver the full spectrum of care that is expected of them.
Allied Health Personnel↗
Evaluation of minor head trauma in children younger than two years.
The recent medical literature emphasizes the limitations of skull films in the evaluation of minor head trauma. However, the emergency medicine literature places little emphasis on the particular risks in children younger than 2 years old with blunt head injury. These children have immature bone and unfused sutures that may increase risk of cranial injury and delayed complications. A case is presented to illustrate this point. Unlike severe head trauma, where evaluation is directed toward computed tomography, the literature continues to be controversial regarding the indications for skull radiographs and computed tomography in minor head trauma. The authors recommend a low threshold for radiographic imaging in blunt heat injuries in children younger than 2 years.
Age Factors↗
Emergency department approach to managing seizures in pregnancy.
Seizures in pregnancy pose risks for both the mother and the fetus and must be managed aggressively. Antiepileptic drugs have some teratogenic potential, but the risks are not as profound as reported in earlier literature. There is definitely less risk to the fetus from anticonvulsant exposure than from uncontrolled seizures. The evaluation of a pregnant woman with new-onset seizures is the same as for the nonpregnant patient, including head computed tomography with appropriate abdominal shielding. Status epilepticus management is based on IV benzodiazepines, phenytoin, or phenobarbital. Good fetal outcome is dependent on rapid seizure control. Management of eclampsia is controversial. There is little evidence that magnesium sulfate has anticonvulsant properties, and its use as such will probably decline steadily in the future. At present, it is reasonable to manage eclamptic seizures in the same way that status epilepticus is managed.
Eclampsia↗
Infant botulism: case report and clinical update.
Infant botulism occurs in infants between 1 week and 11 months of age and results from the in vivo production of neurotoxin by Clostridium botulinum. The clinical spectrum ranges from asymptomatic carriers, through various degrees of paralysis, to sudden death. The classic clinical presentation is an afebrile child with constipation and generalized weakness manifested by poor head control, poor suck, and weak cry. Symptoms can progress to include cranial nerve palsies, respiratory arrest, and adynamic ileus. Treatment is supportive in an intensive care setting. Antibiotics and antitoxin are not indicated. The morbidity and mortality is less than 3% in hospitalized patients and complete recovery can be expected. The environmental and dietary factors associated with infection are discussed.
Botulism↗
Nonconvulsive status epilepticus in adults.
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Adult↗
Cephalic tetanus: a case report and review of the literature.
Cephalic tetanus is a rare form of tetanus defined as trismus plus paralysis of one or more cranial nerves. The most frequently involved cranial nerve is the seventh. It accounts for 1 to 3% of the total number of reported cases of tetanus and has a mortality of 15 to 30%. The incubation period is 1 to 14 days, and approximately two thirds of cases progress to generalized tetanus. The mechanism of the paralysis is not completely understood. Treatment involves debridement of wounds, administration of penicillin and tetanus immune-globulin, aggressive supportive care, and initiation of active immunization.
Facial Injuries↗
A friction blister prevention study in a population of marines.
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Blister↗
In vivo assessment in sheep of thromboresistant materials by determination of platelet survival.
The thromboresistance of 13 potentially blood-compatible polymers was assessed in sheep by determining survival of 51Cr-labeled platelets. Polymer tubing (120-150 cm x 2.0-2.3 mm i.d.) coiled around the neck was incorporated into the circulation through silicone rubber connectors as a carotid artery-external jugular vein shunt. The mean platelet half-life in control animals ("shunt control") was 78.2 +/- 2.8 (SEM) hours. Eleven of the 13 polymers tested significantly shortened platelet half-life. Polyvinyl chloride (T1/2 = 45.4 +/- 3.0 hours), polyperfluoro ethylene (T1/2 = 47.0 +/-1.6 hours), and a polymethylacrylate (PMA)/acrilonitrile copolymer (T1/2 = 50.7 +/- 7.0 hours) produced the greatest shortening. Only silica-free polydimethyl siloxane (T1/2 = 74.7 +/- 4.9 hours) and PMA (T1/2 = 81.5 +/- 3.4 hours) were indistinguishable from shunt controls. Pretreatment of PMA tubing with autologous plasma in a paired trial significantly increased platelet half-life (P less than 0.05 vs. untreated PMA). This system offers an economical, reproducible, sensitive, and biologically relevant method for assessment of the reactivity of artificial surfaces with platelets.
Animals↗
Psychogenic status epilepticus.
A patient was brought to the Emergency Department in presumed status epilepticus. However, the seizure had many of the clinical characteristics that, in combination, were suggestive of a psychogenic event including asynchronous extremity movements, forward pelvic thrusting, and geotrophic eye movements. An arterial blood gas and serum electrolytes were normal despite one-half hour of tonic-clonic activity, and supported the diagnosis of a nonneurogenic event. The patient became conversant toward the end of the event, which confirmed that the seizure was nonepileptogenic.
Adult↗
Maintenance fluids in prehospital care: crystalloid versus dextrose solutions--is there a difference?
D5W is the maintenance fluid often used in prehospital care when transporting patients with cardiac or central nervous system processes. However, there is evidence that dextrose solutions are potentially harmful, and that suggests isotonic crystalloid solutions are the preferred maintenance fluid in treating emergent patients regardless of their underlying disease. Dextrose solutions may exacerbate cellular ischemic damage and they cannot be used to resuscitate hypotensive patients. Crystalloids do not cause fluid overload when used at maintenance rates and are effective resuscitative agents in managing hypotension. The use of a single crystalloid solution in the prehospital environment would simplify equipment stocking and management protocols, minimize cost, and would not have an adverse impact on patient care.
Animals↗
Emergency medicine at the Mount Sinai School of Medicine.
Emergency medicine became the twenty-third specialty by the American Board of Medical Examiners in 1979. Emergency physicians are specialists in the stabilization and resuscitation of medical and surgical emergencies in patients of all ages; they are experts in triage and in prioritization of resources. Emergency physicians provide the "safety net" for the American health care system, and they are the facilitators between the community and health care systems, and between primary care physicians and specialists. The emergency department is an ideal environment in which to teach the assessment and management of patients presenting with undifferentiated processes. Emergency physicians possess a unique set of clinical and research skills that have made them valuable members of the medical school academic community. Presented is a historical perspective on the specialty of emergency medicine and its evolving role at the Mount Sinai School of Medicine. Included are discussions on innovations in teaching developed by the emergency medicine faculty, including applications of computer-assisted instruction and the Internet.
Computer-Assisted Instruction↗
The evaluation and treatment of seizures in the emergency department.
One to two percent of visits to the emergency department are due to seizures. These patients may require aggressive stabilization and resuscitation and concurrent implementation of diagnostic testing, monitoring, and pharmacologic interventions. Seizures are usually a manifestation of an underlying pathology which requires thorough evaluation, including a careful history, physical examination, laboratory work-up, and electroencephalographic and neuroimaging studies as dictated by clinical suspicion. The evaluation and treatment of seizures in the emergency department must be comprehensive, including giving consideration to the patient's medical and social resources.
Child, Preschool↗
Management of life-threatening asthma in the emergency department.
Acute asthma exacerbations are frequent presentations to the emergency department. Those patients who deteriorate despite nebulized beta-agonist therapy and intravenous steroids are experiencing a life-threatening event. They pose a significant management challenge to the emergency physician. This review describes the pharmacologic options and techniques for mechanical ventilation which are available in resuscitating these patients.
Adrenergic beta-Agonists↗