Biomedical subjects
Publications and source records attributed to J S Olshaker.
Heat stroke is reviewed in detail. Particular attention is paid to diagnosis and current emergency department treatment, and a brief overview of pathophysiology is included. Early complications, with recommendations for prevention and management, are described. Minor heat related syndromes are also mentioned.
Many thousands of individuals are near drowning victims each year in this country. The majority of these will be young, previously healthy people. The key to their successful outcome and return to productive, full lives is aggressive resuscitation by emergency physicians and prehospital care providers. After multiple studies over many years there is consensus on one point: the most important enemy of the near drowning victim is hypoxia. Attention should be focused on immediate institution of resuscitative measures at the earliest possible opportunity, and the basic principles of both ACLS and ATLS. Finally, most of these near drownings should never take place. Emergency physicians must take the lead in public education on prevention of drowning and near drowning.
Cervical spinal epidural hematoma is an infrequent entity that usually requires emergency decompressive therapy because of rapid neurologic dysfunction. We present the case of a 34-year-old man who presented to the emergency department with minimal symptomatology after a stab wound to the neck. A computed tomography myelogram of the cervical spine revealed a cervical spinal epidural hematoma. This case illustrates an unusual presentation as well as etiology of cervical spinal epidural hematoma.
Peripheral venous access can often be difficult to obtain in infants and young children. Landmark articles in the 1940s showed that the intraosseous (IO) route was a viable one for resuscitation. While anecdotal reports and clinical experience suggest that blood products can be transfused via the IO route, it has not been specifically studied nor documented. We performed a prospective study to document the feasibility of red blood cell transfusion via the IO space. We studied the rapid infusion of 51Cr-labeled red blood cells via the IO space through an 18-gauge IO needle in three normovolemic immature swine. Serial central venous samples were removed at 30 seconds and at 1, 5, 15, 30, and 60 minutes and analyzed for evidence of radiolabeling. Our results revealed rapid delivery of radiolabeled red blood cells into the central circulation with no evidence of early heomolysis. Highest counts were seen in samples taken at 30 seconds to 1 minute. We conclude that the IO route is a viable means for blood transfusion in a nonhemorrhagic model.
STUDY OBJECTIVE: To determine the effectiveness of IV metoclopramide as sole therapy for relieving the pain of acute migraine in the emergency department. DESIGN: Prospective study. Fifty patients were divided randomly into subjects and placebo controls with blinding of the treating physician and the patient. PARTICIPANTS: Patients presenting to the ED with migraine requiring parenteral treatment. INTERVENTIONS: Subjects received 10 mg IV metoclopramide and controls received IV normal saline; patient assessment of relief was followed by means of a numerical scale. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent of subjects compared with 19% of controls had effective pain relief within one hour (P less than .001). Subjects achieved mean relief scores of 2.46 compared with 1.69 for controls (P less than .02). No significant side effects were observed. CONCLUSION: IV metoclopramide as a single agent is effective and safe therapy for migraine in the ED.
The case of a patient with left ventricular rupture as a result of blunt chest trauma from a motor vehicle accident is presented. This is the first reported case of a pediatric survivor of this rare and usually lethal injury and only the fourth report of a survivor. This condition can be treated if the patient survives long enough to reach a trauma center, if the diagnosis is entertained early, and if the appropriate diagnostic studies are obtained in an expeditious manner. We believe that echocardiography is the diagnostic method of choice for pericardial tamponade, whether it is the result of penetrating or blunt trauma, and that early use of this modality may improve survivability.
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Nontraumatic intracerebral hemorrhage is an uncommon occurrence in young adults. Signs and symptoms may be subtle or atypical and predisposing factors absent in patients with computed tomography or magnetic resonance imaging-proven hemorrhage. Rapid evaluation and referral to a neurosurgeon are critical if consequent morbidity and mortality are to be minimized. Presented are the cases of two patients in their early thirties with computed tomography or magnetic resonance imaging-proven intracerebral hemorrhage. These cases vividly demonstrate that in young adults there is a need to maintain a high index of suspicion and consideration of intracerebral hemorrhage before signs and symptoms are attributed to less malignant disease processes.
Acute gastrointestinal disorders are among the most common problems encountered by the emergency physician. Serum electrolytes are commonly ordered in the evaluation of patients with gastroenteritis. We retrospectively reviewed the charts of all 281 patients with a discharge diagnosis of acute gastroenteritis seen in our emergency department during a recent six-month period. Electrolytes were ordered on 207 of these patients, and the time spent in the ED was three to four times longer for patients on whom electrolytes were ordered. Of these 207, 24 (11%) had electrolyte abnormalities, but only two (1%) had clinically significant electrolyte abnormalities, which were defined as values that affected patient treatment or disposition. On presentation, 56 patients (27%) had orthostatic vital sign changes (defined as a pulse increase of 30 or more on standing). Five (10%) had electrolyte abnormalities. None of the abnormalities were clinically significant. Eleven patients (5%) were hospitalized. One patient had electrolyte abnormalities that were not the cause of hospitalization. No patients with uncomplicated gastroenteritis alone had clinically significant electrolyte abnormalities. We conclude that there is no justification for the routine ordering of serum electrolytes on the adult patient with acute gastroenteritis.
Meckel's diverticulum is a cause of significant morbidity and mortality. Often this is related to the delay in diagnosis. Based on a US population of 200 million people and a 2% incidence, there are 4 million Meckel's diverticula present waiting to cause symptoms. Considering that most Meckel's diverticula are asymptomatic and that many authors have described the condition as a great mimic, the diagnosis is often quite elusive. Therefore, a high index of suspicion is needed to diagnose Meckel's diverticulum correctly and expeditiously as the source of disease in the patient with an often unclear abdominal presentation. The difficulty with diagnosis should be lessened if one considers that Meckel's diverticulum presents largely in the male and younger age groups with the three major symptom complexes of bowel obstruction, gastrointestinal bleeding, and inflammation. Use of 99mTc pertechnetate scintigraphy appears to be the diagnostic study of choice if Meckel's diverticulum is suspected and the patient is clinically stable. When one considers the potential for bad outcome if Meckel's diverticulum is missed in the setting of possible obstruction or hemorrhage (i.e., bowel infarction or exsanguination), a high index of suspicion and diagnostic aggressiveness is warranted. Lastly, if one thought is to be left behind, it should be: "Meckel's is a great mimic that must be considered in all cases of intra-abdominal disease in which the cause is not readily apparent."
This case report presents the resuscitation of a 6 1/2-month-old child with elevated intracranial pressure, seizure activity, and a presumptive diagnosis of shaken child syndrome. It is unique in the usage of an intraosseous infusion line for the administration of muscle relaxants and anesthetic agents to aid in an atraumatic intubation in this head-injured child. This is an original report of the usage of the intraosseous line for the administration of succinylcholine chloride, atracurium besylate, and thiopental sodium.
Atrial flutter is a supraventricular tachydysrhythmia believed to arise from electrophysiologic disturbances in the atria. It tends to be an unstable rhythm and is usually associated with intrinsic cardiac or pulmonary disease or adverse extrinsic influences on the heart. It is due to either a reentry mechanism or an increased atrial automaticity. Atrial depolarization is regular at a rate of 260 to 340 beats per minute. With a normal atrioventricular (AV) node there is usually a physiologic second-degree block with resultant 2:1 conduction. Higher degrees of AV block can occur in patients with AV nodal disease, increased vagal tone, or when certain drugs are in use. One-to-one conduction may occur in patients with accessory AV nodal pathways. In this situation, serious adverse effects are often seen, including palpitations, dizziness, syncope, angina, and dyspnea. Electrical cardioversion is the safest and most reliable way of terminating atrial flutter and its use should not be delayed in an unstable patient. In the nonemergent situation a variety of medications alone or in combination can be used to convert the rhythm or slow ventricular response.
Animal laboratories have been used for many years to teach procedures. Our department has a weekly swine laboratory devoted to training residents, interns and students in resuscitative procedures. Physicians who participated in our swine procedure laboratory over the past three years were queried as to their prelaboratory and postlaboratory comfort levels with six different resuscitative procedures, and 57 (76%) physicians responded. Statistical analysis of the data showed significant improvement in comfort levels for all six procedures. Every responder felt the swine laboratory helped or will help them perform the procedures on humans. We also surveyed all U.S. emergency medicine residency program directors from established programs regarding the status of their animal procedure laboratories, and 67 of the 68 (98%) directors responded. Of these responders, 62% offer an animal procedure laboratory. Overall, 97% of the residency directors rated the laboratory successful, and 97% of the residents rated the laboratory successful. Therefore, we conclude that an ongoing emergency medicine animal procedure laboratory is a valuable tool for improving physician-in-training ability and confidence.