On turbulent times for emergency medicine.
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Biomedical subjects
Publications and source records attributed to G R Braen.
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The incidence of ectopic pregnancies has increased dramatically over the past 20 years, resulting in significant maternal morbidity and mortality. This article reviews the epidemiology, pathogenesis, clinical manifestations, diagnostic testing, differential diagnosis, treatment, prognosis, and medico-legal considerations in the evaluation of the patient with a suspected or confirmed pregnancy.
We report the case of a fatal theophylline overdose from a sustained-release preparation in a 54-year-old woman. Initial serum theophylline concentration was 31.3 mg/L. Manifestations of mild toxicity cleared in the emergency department after treatment with gastric lavage, charcoal, and a cathartic. A life-threatening overdose was not suspected, and the patient arrested eight hours after discharge from the ED. At autopsy, her serum theophylline concentration was 190.1 mg/L. A white, waxy mass weighing 318.8 g and containing 29 g theophylline, representing the residue of many sustained-release tablets, was found in her stomach. This case reinforces the importance of obtaining repeat serum theophylline levels in patients with sustained-release theophylline overdose. Gastric pharmacobezoar formation should be considered in cases of sustained-release theophylline overdose with rising theophylline levels and patient deterioration, despite adequate gut decontamination.
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A 17-year-old woman had two admissions within five months for recurrent episodes of ventricular tachycardia in conjunction with a prolonged QT interval. On both occasions these were refractory to intravenous lidocaine and bretylium. During her first admission her dysrhythmia was controlled by repeated doses of intravenous propranolol; however, she required temporary overdrive transvenous pacing on her second admission. On both occasions when the low normal serum potassium was replaced and therapeutic levels of diphenylhydantoin and phenobarbital were obtained, the episodes of ventricular tachycardia subsided. This case illustrates the complexities inherent in making the diagnosis and in treating this syndrome, and should assist the emergency physician in treating this difficult and potentially fatal dysrhythmia.
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Described is the emergency triage referral system developed by a health maintenance organization. Based in an emergency department and staffed by emergency clinicians, this HMO triage system uses existing emergency medical services and enhances the delivery of prehospital care.
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