Biomedical subjects
Publications and source records attributed to J Varon.
Pneumonia is a complication of primary varicella infection that occurs most commonly in adults and may lead to life-threatening respiratory failure. We report a case of varicella pneumonia with impending respiratory failure in which endotracheal intubation was averted by the use of CPAP mask ventilation with a favorable outcome.
Emergency air medical transport has become an integral part of the practice of medicine. In 1990, there were more than 170 air medical programs in operation in the United States. The proper and safe use of air medical transport requires a basic understanding of the medical implications of flight and the capabilities and constraints involved in transporting patients by air. The purpose of this paper is to review this information and provide guidelines for the use of air medical transport.
Carbon monoxide poisoning is a significant health threat in the United States. Smoke inhalation from fires is the most common source. History of carbon monoxide exposure and elevated carboxyhemoglobin levels should alert physicians to the diagnosis of acute poisoning. When there is no history of exposure, carbon monoxide poisoning must be considered when two or more patients are similarly or simultaneously sick. The diagnosis must be excluded by a directed history and physical examination. If suspicion remains, carboxyhemoglobin levels should be determined and oxygen therapy should be started empirically while laboratory results are pending. Prompt administration of hyperbaric oxygen may reduce the risk of death. If carbon monoxide poisoning is confirmed, the source must be identified and recommendations for correction or avoidance should be made.
Hyperphosphatemia is an electrolyte abnormality that most frequently results from renal insufficiency and the attendant inability to excrete phosphorus (PO4) efficiently. A case is presented in which a young man with hemorrhagic shock developed severe hyperphosphatemia in the absence of renal failure. This is the first such case documented to the authors' knowledge. The prompt correction of the primary cause (ie, hypoperfusion and acidosis) resulted in a rapid return of PO4 levels to normal. This was probably related to the intracellular shift of PO4. Physicians should be aware of this electrolyte disturbance because it is not a well-recognized complication and because, in most cases, proper treatment of shock will also correct the elevated PO4.
This case report describes a unique presentation involving avulsion of an ovarian dermoid tumor which occurred as the result of blunt trauma secondary to a motor vehicle collision. Despite an unimpressive initial presentation and normal physical examination, the patient subsequently developed symptoms of severe hemorrhage requiring aggressive intravascular volume resuscitation. A ruptured ovarian dermoid tumor was eventually diagnosed by computerized axial tomography. A review of the literature by the authors did not reveal any similar cases of previous reports of this phenomenon.
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STUDY OBJECTIVE: Heart and heart/lung transplants are accepted forms of therapy for patients with end-stage cardiac or pulmonary disease. These patients are likely to present postoperatively to the emergency department. To our knowledge, there have been no previous reports in the medical literature of the ED presentation of these patients. DESIGN: We conducted a retrospective review of the records of all patients who had received a heart or a heart/lung transplant at Stanford University Medical Center from 1988 through 1990 and who had at least one ED visit. MEASUREMENTS AND RESULTS: Between the time of operation and April 1, 1991, 131 ED visits were recorded. Fever was the single most common presenting complaint, for 48 (37%) of the visits. Difficulty in breathing (13%); gastrointestinal symptoms of nausea, vomiting, or diarrhea (10%); and chest pain (9%) were other common reasons for presentation. CONCLUSION: The transplant patient, by virtue of requiring chronic immunosuppression, is susceptible to infection with a spectrum of opportunistic organisms. When fever or other symptoms suggest infection, appropriate cultures and aggressive diagnostic procedures (eg, lumbar puncture, bronchoscopy) should be performed.
"Adam," "Eve," "ecstasy," "China white." Illicit street drugs such as these are called designer drugs because they are designed to elicit certain effects and to bypass legal classification. Unfortunately, use and abuse of such substances can lead to serious medical problems and even death. Drs Sternbach and Varon describe the best-known compounds and discuss clinical characteristics and management of designer drug intoxication.
Although hypothermia is a serious and sometimes fatal condition, prompt recognition and institution of appropriate rewarming techniques may save even profoundly affected persons. The diagnosis of hypothermia should be considered when patients present with alterations of cerebral function without apparent explanation, especially in the presence of underlying predisposing illnesses and conditions. When hypothermia is suspected, an accurate core temperature must be obtained. Application of rewarming techniques appropriate to the degree of hypothermia may be lifesaving. Conservative use of pharmacotherapy is warranted.
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This often painful disease may be primary or secondary. Simple preventive measures sometimes provide symptomatic control. When such efforts fail, the most effective agents available are calcium channel blockers.
Cardiopulmonary resuscitation (CPR) is attempted every day. Whereas medical professionals and personnel perform these resuscitation attempts, no previous studies have reported the attitudes of medical personnel towards resuscitation for themselves. We have attempted to assess the prevalent attitudes among various physicians at various levels in training and nurses. An eleven item questionnaire was sent to medical students, house officers, attending physicians and registered nurses at university medical centers. Each questionnaire consisted of respondent's sociodemographic information, their attitudes about CPR for themselves and their beliefs about outcome after CPR with particular disease states. The results were analyzed using chi-square analysis. Four hundred questionnaires were mailed and 240 were returned (60% response rate). All groups favored resuscitation in a university hospital over other sites (P less than 0.05). More nurses requested to be 'no code' compared with other professionals (P less than 0.005). Attending physicians requested that CPR attempts be terminated after less time than any other group (P less than 0.005). Medical students requested resuscitation significantly more than any other group in the presence of terminal conditions such as metastatic cancer, acquired immunodeficiency syndrome and severe chronic obstructive pulmonary disease (P less than 0.005). Medical personnel's beliefs about CPR may be influenced by their experiences with particular patients and events. As trainees acquire more experience they appear less inclined to desire resuscitation efforts for themselves.
The authors report a case of a 24-year-old nulligravida woman who presented to the hospital with complaints of severe abdominal pain and radiographic evidence of pneumoperitoneum. She had two prior nondiagnostic laparotomies for similar complaints and radiographic findings. After a careful sexual history was taken the patient revealed that she had sexual intercourse preceding every similar episode including this one, during which her partner forcefully blew air into her vagina. Pneumoperitoneum associated with vaginal insufflation has been previously reported in two multigravida patients with and without anatomic abnormalities. When pneumoperitoneum is present in the absence of gastrointestinal symptoms or trauma, a meticulous sexual history should be made to avoid unnecessary laparotomies.
The hemodynamic effects of captopril and other angiotensin-converting enzyme inhibitors may be mediated by the endogenous opioid system. The opioid antagonist naloxone has been shown to block or reverse the hypotensive actions of captopril. We report a case of an intentional captopril overdose, manifested by marked hypotension, that resolved promptly with the administration of naloxone. To our knowledge, this is the first reported case of captopril-induced hypotension treated with naloxone. Our experience demonstrates a possible role of naloxone in the reversal of hypotension resulting from captopril.
Adenosine is a naturally occurring endogenous nucleoside that suppresses atrioventricular nodal conduction time, terminates supraventricular tachycardia, and restores sinus rhythm. Its use has been reported in children and adults but not in pregnant patients. This case documents the successful termination of a supraventricular tachycardia in a 39-week pregnant hypotensive patient. Emergency physicians may wish to consider adenosine use in pregnant patients needing emergency therapy or when conventional therapy fails.
Parkinson's disease affects thousands of Americans, men and women equally and apparently with little regard to race. Its diagnosis depends largely on repeated clinical observations of representative signs, such as resting tremor, rigidity, bradykinesia, and gait disturbances. Patients progress through stages: Early disease involves only one limb or side and confers minimal disability, but advanced disease restricts patients to full care. Treatment is chosen on the basis of disease stage and patient response. Combination carbidopa-levodopa (Sinemet) is appropriate for any significant degree of disability, and other antiparkinsonian drugs and anticholinergic agents may be used as adjuncts. Electroconvulsive therapy, use of selegiline hydrochloride (Eldepryl), and surgery are still undergoing investigation but may hold promise.