Biomedical subjects
Publications and source records attributed to J I Singer.
Repetitive administration of therapeutic salicylate over 72 hours for amelioration of headache produced severe central nervous system manifestations in an adolescent. The simultaneous occurrence of bacterial meningitis was not promptly diagnosed. Treatment directed at correcting fluid and metabolic derangements of salicylism may have contributed to a morbid outcome.
A case of lactobezoar is described in a toddler with an acute history of abdominal pain, vomiting, and lethargy. Despite normal dietary habits, he had developed a gastric milk coagulum which led to a palpable epigastric tumor. Intussusception was suspected but disproven by barium enema. In retrospect, plain abdominal radiographs demonstrated characteristic mottled filling defects in the stomach from a lactobezoar. Conservative therapy led to prompt disintegration of the lactobezoar.
Osteomyelitis in the neonate is an entity distinct from that in older children. We report a case that had a benign onset, insidious course, and multiple foci of involvement. The unique metaphyseal blood supply of early infancy permitted coexisting septic arthritis. Signs of limb disuse, limitation of motion, and swelling over distal bone or joint space should prompt the emergency physician to entertain the possibility of osteomyelitis. Early diagnosis and intervention on the part of the emergency physician may prevent or alleviate sequelae of this disease.
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Expected clinical manifestations of intussusception include paroxysmal abdominal pain, vomiting, abdominal mass, and with time, rectal bleeding. We report a case where lethargy and vomiting are the presenting complaints. Diagnostic delay was encountered for this infant who had altered sensorium without accompanying pain, melena, or mass on initial examination. Either plain radiographs, supplemented by ultrasonography of the abdomen, or a barium enema should be performed in infants with unexplained lethargy.
A child with a past history of wheezing presented with an acute illness that simulated an asthma attack. Respiratory distress was not alleviated by nebulized and parenteral therapy for status asthmaticus. The diagnosis of posterolateral diaphragmatic hernia became obvious only when a radiograph demonstrated gas-filled loops of bowel in a hemithorax. The clinician must entertain the diagnosis of congenital diaphragmatic hernia in patients with apparent bronchospasm.
The superiority of either a complete blood count, erythrocyte sedimentation rate, or C-reactive protein as a generic, global screening test for bacterial infection in infants or children has not been clearly demonstrated. The few claims of superiority for one determination over another relate more to the clinical setting than marginal differences in sensitivity or specificity. Neither the complete blood count, erythrocyte sedimentation rate, or C-reactive protein has proved sensitive enough of predicting invasive bacterial infection that it can be used as an isolated measure upon which major management decisions can safely be based. Several investigators have therefore addressed whether these tests can complement each other. Unfortunately, acquisition of multiple nonspecific laboratory tests in a given clinical situation may yield widely divergent results. The C-reactive protein, complete blood count, erythrocyte sedimentation rate, and zeta sedimentation ratio are all comparably priced in the $15.00 to $30.00 range. However, if multiple tests are obtained, the cost of this approach may become unacceptably high. Current practice advocates a careful evaluation of an ill pediatric patient in an Emergency setting. The initial clinical impression of an experienced clinician based on history and physical examination frequently provides dependable information with which to direct subsequent evaluation. If bacterial infection ranks high on the differential list, relevant laboratory studies should be considered. Observation of quantitative and qualitative changes of the hematologic profile or rate of erythrocyte sedimentation are adequate tools in specific circumstances. With the resurgence of interest in the use of C-reactive protein, it too may join the ranks of convention in selected settings.
Children who seek attention for painful or painless alteration of gait provide a challenge to the emergency department physician who confronts such cases. Children with acute onset of limp or refusal to walk may become the center of diagnostic and therapeutic concern in approximately 4 percent of pediatric patient encounters. The spectrum of diagnoses found in both the outpatient and inpatient populations is extensive. Among the diverse afflictions that can cause nontraumatic altered locomotion in children, infectious diseases predominate. This finding influences a liberal admission policy for patients with altered gait who may have historical, physical, or laboratory features suggestive of an infectious disease.
Growth and maturation in the delivery of prehospital emergency medical care has been dramatic in the past 15 years. The increased availability and use of emergency medical services (EMS) has led to more frequent interactions between providers of prehospital care and the medical practitioner. This paper reviews the training and capabilities of emergency medical personnel and introduces the issue of medical control at the scene of an emergency. Also presented are the basics of emergency scene and victim stabilization. Physicians can help improve prehospital care by becoming familiar with local EMS capabilities and personnel.
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The publication of textbooks that are relevant to emergency medicine has increased rapidly during the past decade. This increase has created confusion in the selection of appropriate texts for both emergency medicine residency and hospital emergency department libraries. A critical review of 703 pre-selected texts was performed. From this review, a recommended list of 165 books for the resident library and 27 books for the emergency department library is suggested. The cost of these libraries is $6,433.05 and $1,230.05, respectively. The libraries are designed to assist emergency physicians and librarians in attaining maximum value in the expensive process of textbook selection.
Antibiotic therapy for children without foci of infection and at risk for bacteremia is controversial. A prospective randomized clinical trial was conducted using expectant antibiotic therapy in children at risk for bacteremia. A total of 96 children (aged 6 to 24 months) with temperature of more than 40 degrees C, no identifiable source of infection, and a leukocyte count greater than or equal to 15,000/microL and/or sedimentation rate greater than or equal to 30 were enrolled. The following tests were performed on all children: blood culture, chest roentgenogram, urinalysis, and urine culture. A lumbar puncture was performed if a child was 12 months or less. Patients were randomized to receive either no antibiotic therapy or Bicillin C-R, 50,000 U/kg intramuscularly, followed by penicillin V, 100 mg/kg/d, orally four times a day for three days. Patients were examined at 24 and 72 hours. Fifty patients were treated expectantly and 46 received no antimicrobial therapy. Ten of the 96 patients were bacteremic (nine had Streptococcus pneumoniae, one had Haemophilus influenzae). Four of the five children treated for bacteremia showed improvement at the first follow-up visit (afebrile and no obvious focus of infection). The five untreated patients showed no improvement; four patients developed focal infections (two had meningitis, two had otitis media) (P less than or equal to .05, Fisher exact test). No complications of expectant therapy were detected. Thus, expectant antibiotic therapy for children who have no obvious source of infection and who meet these criteria associated with occult bacteremia is warranted.
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Four hundred and fifty-six patients with signs and symptoms of potential central nervous system infection were evaluated from June 28, 1978, to September 30, 1978. The majority of the children had a relatively brief and mild illness characterized by a constellation of features previously described with central nervous system infections. Fever, headache, and vomiting were typical. Altered sensorium and nuchal rigidity were inconstant. One distinct and another infrequently reported feature of enteroviral disease, hypoglycorrhachia and cerebrospinal fluid pleocytosis in excess of 2,000 cells/mm3, occurred independently or in concert in 18% of the cases. When these unexpected findings were associated with a presumptive clinical diagnosis of aseptic meningitis, watchful observation and repeat lumbar puncture precluded the necessity to administer antibiotics in every case. The possibility of enteroviral aseptic meningitis being a definitive diagnostic entity manageable on a group, yet individual basis utilizing a disposition protocol is discussed.
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This is the 16th in a series of objectives to direct resident training in Emergency Medicine. Research is recognized as an important component of physician training, yet it is often neglected in medical school and residency curricula. We offer here an objective-based program for resident physicians' exposure to research design and methodology.
This article outlines the objectives for a resident rotation in an in-patient pediatric service. The objectives can be successfully implemented in a 2-month sequential exposure to an in-patient ward service followed by an intensive care unit rotation in the first year of postgraduate training. These objectives are a part of a continuing series in the goals and objectives to direct emergency medicine resident training on off-service rotations.
This article outlines the objectives for a resident rotation on a pediatric emergency medicine service that is geographically separate from adult-oriented facilities. In this setting, pediatric emergency department care is considered an off service. However, these objectives incorporate key pediatric knowledge and techniques in a practical format for emergency medicine trainees who have no separate pediatric emergency department experience. The content of the pediatric emergency department educational exposure can be attained in a concentrated 2-month exposure at a pediatric facility or extracted throughout the course of multiple pediatric encounters at a general emergency department. These objectives are a part of a continuing series on the goals and objectives to direct emergency medicine resident training on off-service rotations.