American Journal of Emergency Medicine

Masthead

2010-01-01

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

2009-10-26

Abstract: Objectives: We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access.Methods: This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis.Results: Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications.Conclusion: Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

Oral N-acetylcysteine has a deleterious effect in acute iron intoxication in rats

2009-10-26

Abstract: Acute iron intoxication is associated with depletion of reduced glutathione in hepatocytes and changes in the glutathione system enzymes. We hypothesized that treatment with N-acetylcysteine (NAC), a glutathione reducing agent and an antioxidant, would reduce mortality in acute iron intoxication. We used a rat model to test this hypothesis. Male rats were assigned to 4 groups. Group 1 received 400 mg/kg elemental iron by oral gavage, group 2 received the same dose of iron followed by NAC, group 3 received NAC only, whereas group 4 received distilled water. Iron and liver transaminases in the blood, and glutathione system enzymes in the liver and erythrocytes were measured. Mortality in group 2 was significantly higher after 2, 6, and 24 hours compared with group 1 (P < .001). No deaths were observed in groups 3 and 4. Serum iron levels were significantly higher in group 2 rats compared to group 1 rats (P < .001). Hepatic and erythrocyte glutathione system enzymes were significantly lower among rats in group 2 compared to rats in group 1. The administration of NAC probably increased the absorption of iron through the gastrointestinal tract, causing higher serum iron levels with significant hepatic damage. These results indicate that in a rat model of acute iron intoxication, orally administered NAC may increase mortality.

Diagnostic utility of the genital Gram stain in ED patients

2009-10-26

Abstract: Objective: The study aimed to determine the diagnostic usefulness of the genital Gram stain in an emergency department (ED) population.Methods: A linked-query of an urban, tertiary-care, university- affiliated hospital laboratory database was conducted for all completed Chlamydia trachomatis and Neisseria gonorrhoeae DNA probes, Trichomonas vaginalis wet preps, and genital Gram stains performed on ED patient visits between January and December 2004. Positive criteria for a Gram stain included greater than 10 white blood cells per high-power field, gram-negative intracellular/extracellular diplococci (suggesting N gonorrhoeae), clue cells (suggesting T vaginalis), or direct visualization of T vaginalis organisms. DNA probes were used as the gold standard definition for N gonorrhoeae and C trachomatis infection.Results: Of 1511 initially eligible ED visits, 941 were analyzed (genital Gram stain and DNA probe results both present), with a prevalence of either C trachomatis or N gonorrhoeae of 11.4%. A positive genital Gram stain was 75.7% sensitive and 43.3% specific in diagnosing either C trachomatis and/or N gonorrhoeae infection, and 80.4% sensitive and 32.2% specific when the positive cutoff was lowered to more than 5 white blood cells/high-power field. No Gram stains were positive for T vaginalis (with 47 positive wet mounts), and clue cells were noted on 117 Gram stains (11.6%).Conclusion: Gram stains in isolation lack sufficient diagnostic ability to detect either C trachomatis or N gonorrhoeae infection in the ED.

Patients with coronary disease fail observation status at higher rates than patients without coronary disease

2009-10-21

Abstract: Background: Few studies have evaluated emergency department (ED) observation unit chest pain protocols for optimal patient characteristics and admission rates. At our 35 000-visits/y ED, we implemented a chest pain protocol for our observation unit that allowed emergency physicians to admit patients with known coronary artery disease (CAD).Methods: We performed a retrospective chart review of all observation unit patients admitted under the chest pain protocol from April 1, 2006, to May 31, 2007. We compared the outcomes of patients who had a history of CAD with those who did not.Results: Five hundred thirty-one patients were admitted to the observation unit under the chest pain protocol for the 14-month study period. Of these patients, 125 (23.5%) had a history of CAD. Patients with a history of CAD had a higher inpatient admission rate ( 24% vs 8.6%; P < .001), higher rate of a positive stress test or positive coronary computed tomographic scan (32.3% vs 6.9%; P < .001), a higher rate of cardiac catheterization (12% vs 5.9%; P = .02), and a higher rate of stent placement or coronary artery bypass graft (CABG) (7.2% vs 2.2%; P = .007). In multivariate analysis, patient history of CAD was an independent predictor of hospital admission (P = .005) and stent placement or CABG (P = .030).Conclusion: Patients with known CAD who were admitted to the ED observation unit failed observation status (ie, required hospitalization) and had higher rates of positive testing than those without CAD.

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception

2009-10-22

Abstract: Objective: The study aimed to determine if emergency department (ED)–administered antibiotics for patients discharged home with nonpneumonia acute respiratory tract infections (ARIs) have increased since national pneumonia performance measure implementation, including antibiotic administration within 4 hours of arrival.Methods: Design: Time series analysis. Setting: Six university and 7 Veterans Administration EDs participating in the Improving Antibiotic Use for Acute Care Treatment (IMPAACT) trial (randomized educational intervention to reduce antibiotics for bronchitis). Participants: Randomly selected adult (age >18 years) ED visits for acute cough, diagnosed with nonpneumonia ARIs, discharged home during winters (November-February) of 2003 to 2007. Main outcome: Time trend in ED-administered antibiotics, adjusted for patient demographics, comorbidities, vital signs, ED length of stay, IMPAACT intervention status, geographic region, Veterans Administration/university setting, and site and provider level clustering.Results: Six thousand four hundred seventy-six met study criteria. Three hundred ninety-four (6.1%) received ED-administered antibiotics. Emergency department–administered antibiotics did not increase across the study period among all IMPAACT sites (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.76-1.01) after adjusting for age, congestive heart failure history, temperature higher than 100°F, heart rate more than 100, blood cultures obtained, diagnoses, and ED length of stay. The ED-administered antibiotic rate decreased at IMPAACT intervention (OR, 0.80; 95% CI, 0.69-0.93) but not nonintervention sites (OR, 1.04; 95% CI, 0.91-1.19). Adjusted proportions receiving ED-administered antibiotics were 6.1% (95% CI, 2.7%-13.2%) for 2003 to 2004; 4.8% (95% CI, 2.2%-10.0%) for 2004 to 2005; 4.6% (95% CI, 2.7%-7.8%) for 2005 to 2006; and 4.2% (95% CI, 2.2%-8.0%) for 2006 to 2007.Conclusions: Emergency department–administered antibiotics did not increase for patients with acute cough discharged home with nonpneumonia ARIs since pneumonia antibiotic timing performance measure implementation in these academic EDs.

How stylet use can effect confirmation of endotracheal tube position using ultrasound

Erkan Göksu, Vefa Sayraç, Cem Oktay, Mutlu Kartal, Mehmet Akcimen — 2009-10-26

Abstract: Introduction: None of the techniques used for confirmation of endotracheal tube (ET) placement are proven reliable 100% of the time. The purpose of our study is to determine whether ultrasound can accurately detect the passage of ET through the trachea and esophagus and to see whether this visualization is augmented with the use of a metal stylet.Methods: A total of 7 physicians made assessments of ET positions using an ultrasound during their passage through the trachea or esophagus. A total of 40 esophageal and 40 tracheal intubations were performed randomly in a blinded fashion on a fresh, unfrozen human cadaver. Half were performed with a metal stylet and the other half without a stylet.Results: During transtracheal assessment regardless of stylet use, correct identification of ET position was achieved in 275 of 280 esophageal intubations and 268 of 280 tracheal intubations. The overall sensitivity was 95.7%, and specificity was 98.2%. The presence and the absence of stylet was identified in 109 of 280 and in 155 of 280 attempts, respectively. Correct identification of stylet presence yielded a sensitivity of 38.9% and a specificity of 55.4%.Ultrasound can be used by emergency physicians to accurately detect the passage of ET through the trachea and esophagus; however, stylet use did not augment ET visualization.

Can hypertonic saline influence platelet P selectin expression and platelet-leukocyte aggregation?

2009-10-26

Abstract: Objectives: Part of platelet function involves aggregation and activation. Activation leads to platelet P selectin expression and platelet-leukocyte aggregation. Hypertonic saline inhibits platelet aggregation, although the effects of hypertonic saline on platelet activation are not known. We evaluated the effects of hypertonic saline on platelet activation as measured by platelet P selectin expression and platelet-leukocyte aggregation.Methods: Blood samples from healthy volunteers (n = 6) were treated in vitro with various solutions including 23.5%, 7.5%, 3%, and 0.9% saline; Ringer's solution; 5% dextrose in water; and 10% hydroxyethyl starch. Blood was diluted with each type of solution to 2.5%, 5%, 10%, 20%, and 30% (vol/vol) dilution. All blood samples were activated with adenosine diphosphate (20 μmol/L), stained with fluorochrome-conjugated antibodies, and analyzed by flow cytometry to measure platelet P selectin expression and platelet-leukocyte aggregation.Results: The 23.5% saline solution reduced P selectin expression at 20% and 30% dilutions and platelet-leukocyte aggregation at 10%, 20%, and 30% dilutions. The 7.5% solution saline had no effect on P selectin expression and significantly inhibited platelet-leukocyte aggregation only at 30% dilution. Other solutions had no effect on platelet P selectin expression or platelet-leukocyte aggregation.Conclusions: Our data suggest that hypertonic saline does not affect platelet P selectin expression or platelet-leukocyte aggregation at therapeutic plasma concentrations but that an inhibitory effect occurs at supratherapeutic doses. Dilutions of other solutions caused the least disturbance of platelet activation.

Validating the ABCD2 Score for predicting stroke risk after transient ischemic attack in the ED

Marcus Eng Hock Ong, Yiong Huak Chan, Wan Ping Lin, Wan Ling Chung — 2009-10-26

Abstract: Objectives: The aim of the study was to validate the use of the ABCD2 score for the prediction of stroke after transient ischemic attack (TIA) in patients presenting to the emergency department (ED). The ABCD2 scoring is based on 5 factors as follows: age of at least 60 years; blood pressure of at least 140/90 mm Hg; clinical features such as unilateral weakness and speech impairment alone; duration of at least 60 minutes or 10 to 59 minutes; and diabetes.Methods: The authors conducted a retrospective observational study of all patients presented to the ED for TIA, as diagnosed by the attending emergency physicians, for a 2-year period. Sensitivity, specificity, and negative predictive value (NPV) were calculated for risk of stroke at 2, 7, 30, and 90 days after presentation.Results: From January 1, 2005, to December 31, 2006, there were 470 patients diagnosed with TIA at the ED. Mean age was 61.0 years (SD, 13.2), with 63.3% males. Age of at least 60 years, unilateral weakness, and duration of at least 60 minutes were found to be significant predictors of stroke at 2 days. An admission rule based on an ABCD2 score of at least 4 showed sensitivity of 86.4% and NPV of 91.7% for stroke at 7 days. Admission based on a score of at least 3 showed sensitivity of 96.6% and NPV of 96.1%. Admission rate was 69.1% and. 83.6%, respectively.Conclusion: The ABCD2 rule showed good sensitivity and NPV for stroke at 7 days. However, NPV was not 100%, and there would still be patients being discharged from the ED and returning with a stroke if this cutoff was implemented in our setting.

Echocardiographic evaluation of TASER X26 probe deployment into the chests of human volunteers

Donald M. Dawes, Jeffrey D. Ho, Robert F. Reardon, James R. Miner — 2009-10-26

Abstract: Several animal studies have shown that the TASER X26 (TASER International, Scottsdale, Ariz) conducted electrical weapon can electrically capture the myocardium when discharged on the thorax. These results have not been reproduced in human echocardiographic studies. A primary limitation of those human studies is that the TASER device was connected by taping the wires into conductive gel on the skin surface of the thorax. This study overcomes those limitations. In this study, a training instructor discharged a TASER X26 into the chests of 10 subjects from a distance of 7 ft so that a 5-second discharge could be administered through the probes as in field exposures. Limited echocardiography was performed before, during, and after discharge. In agreement with 2 prior studies by these authors, the TASER X26 did not electrically capture the human myocardium when used with probe deployment. These data are contrary to animal studies in which capture occurred.

Demographics of patient visits during high daily census in a pediatric ED

Nathan L. Timm, Richard M. Ruddy — 2009-10-26

Abstract: Purpose: The aim of this study is to describe patient demographics in a pediatric emergency department (PED) during low, average, and high daily census days.Methods: Daily PED census, between January 1, 2006, and December 31, 2006, was categorized into very low, low, average, high, and very high quintiles. Variables of interest included acuity, age, health care coverage, and disposition. χ2 analysis assessed the significance of differences in proportions of patient populations across the census quintiles.Results: An increasing proportion of younger children (<2 years of age) received care as daily volumes increased (P < .0001). Proportions of Medicaid and self-pay patient increased, whereas that of commercially insured patients decreased as daily census increased (P < .0001). The distributions of patient acuity level (63.1% nonurgent) and admission rate (12.8%) did not differ significantly cross census quintiles.Conclusions: Younger children with self-pay and government-assisted health care coverage make up a greater proportion of children seen in a PED during high census days.

S-100β and neuron-specific enolase levels in carbon monoxide–related brain injury

2009-10-26

Abstract: Introduction: Carbon monoxide (CO) toxicity may cause persistent injuries in tissues sensitive to hypoxia. Neuropsychiatric sequelae may be observed in about 67% of cases after severe CO exposure.Aim: The aims of this study were to demonstrate the usefulness of S-100β and neuron-specific enolase (NSE) in CO intoxications, show the degree of neurological response, and determine the indications for hyperbaric oxygen treatment (HBOT) as biochemical markers.Results: The S-100β and NSE levels of the sera of 30 patients were studied upon admittance and at the third and sixth hours. S-100β levels were found to be high in all 3 analyses. There was no significant change in NSE levels. When the S-100β levels were compared with Glasgow Coma Scale levels, a strong negative correlation was found for all hours (r = −0.7, −0.8; P = .00). The correlation between S-100β and carboxyhemoglobin levels at the initial hour was found to be statistically significant (r = 0.4; P = .01). The S-100β levels in patients receiving HBOT showed a considerable decrease compared with those in patients not receiving the treatment. The same decrease was valid for NSE, although it was insignificant.Conclusion: S-100β may be useful in evaluating intoxications as an early biochemical marker in CO intoxications, as well as in the differential diagnosis due to other causes, and in determining HBOT indications.

Alcohol, bicycling, and head and brain injury: a study of impaired cyclists' riding patterns R1

Patrick Crocker, Omid Zad, Truman Milling, Karla A. Lawson — 2009-10-09

Abstract: Objective: The aim of the study was to examine the interactions between alcohol, bicycle helmet use, experience level, riding environment, head and brain injury, insurance status, and hospital charges in a medium-sized city without an adult helmet law.Methods: A study of adult bicycle accident victims presenting to a regional trauma center over a 1-year period was undertaken. Data were collected at the bedside regarding helmet use, alcohol use, experience level, location and type of accident and prevailing vehicle speed (for road accidents), and presence and degree of head or brain injury.Results: Two hundred patients 18 years or older were enrolled from December 2006 through November 2007. Alcohol use showed a strong correlation with head injury (odds ratio, 3.23; 95% confidence interval, 1.57-6.63; P = .001). Impaired riders were less experienced, less likely to have medical insurance, rarely wore helmets, were more likely to ride at night and in slower speed zones such as city streets, and their hospital charges were double (all P values <.05).Conclusions: Alcohol use leads to a host of unsafe bicycling practices, increased head and brain injuries, and costs to the cyclist and community. The interrelated characteristics of the riding patterns of the cyclists who use alcohol might help target interventions.

Computed tomographic screening for thoracic and lumbar fractures: is spine reformatting necessary?

Eric A. Gross — 2009-10-26

Abstract: Introduction: Patients who sustain traumatic vertebral fractures often have multiple other associated injuries. Because of the mechanisms of injury, many of these patients routinely undergo chest computed tomographic (CCT) and/or abdominal/pelvic computed tomographic (APCT) scans to diagnose intrathoracic or intra-abdominal injuries. These scans are routinely reformatted to provide more detailed imaging of the spine. Although the patient does not incur more radiation, the charges associated with this are significant. This study compared the sensitivity of these CT modalities in detecting thoracolumbar spine fractures.Methods: A retrospective chart review identified blunt trauma victims, admitted through the emergency department, with a discharge diagnosis of thoracic or lumbar spine fracture that received (1) a chest and T-spine CT, (2) an abdominal/pelvic and lumbar spine CT, or both. Final radiologic readings of these patients' CT scans were obtained, and the sensitivities of the different imaging methods were compared. Discharge diagnosis of spine fracture was considered the gold standard.Results: One hundred seventy-six APCT scans with reformatting and 175 CCT scans with reformatting were available for comparison. There were 9 of 176 false-negative APCT scans vs 3/176 false-negative lumbar spine CT scans. There were 14/175 false-negative CCT scans vs 2/175 false-negative thoracic spine CT scans. The differences in sensitivity were significant (P < .001) for both comparisons.Conclusions: Reformatting of CCT and APCT scans gives improved sensitivity in the detection of thoracic and lumbar spine fractures in trauma patients. Future study looking at clinically significant fractures or those that change clinical management decisions may find that the reformatted images are not routinely needed as a screening tool.

Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures

Francesca L. Beaudoin, Arun Nagdev, Roland C. Merchant, Bruce M. Becker — 2009-11-04

Abstract: Objectives: The primary objective of this study was to determine the feasibility of ultrasound-guided femoral nerve blocks in elderly patients with hip fractures in the emergency department (ED). The secondary objective was to examine the effectiveness of this technique as an adjunct for pain control in the ED.Methods: This prospective observational study enrolled a convenience sample of 13 patients with hip fractures. Ultrasound-guided femoral nerve block was performed on all participants. To determine feasibility, time to perform the procedure, number of attempts, and complications were measured. To determine effectiveness of pain control, numerical rating scores were assessed at baseline and at 15 minutes, 30 minutes, and hourly after the procedure for 4 hours. Summary statistics were calculated for feasibility measures. Wilcoxon matched-pairs signed-rank tests and Friedman analysis of variance test were used to compare differences in pain scores.Results: The median age of the participants was 82 years (range, 67-94 years); 9 were female. The median time to perform the procedure was 8 minutes (range, 7-11 minutes). All procedures required only one attempt; there were no complications. After the procedure, there were 44% and 67% relative decreases in pain scores at 15 minutes (P ≤ .002) and at 30 minutes (P ≤ .001), respectively. Pain scores were unchanged from 30 minutes to 4 hours after the procedure (P ≤ .77).Conclusions: Ultrasound-guided femoral nerve blocks are feasible to perform in the ED. Significant and sustained decreases in pain scores were achieved with this technique.

Ultrasound detection of guidewire position during central venous catheterization

Michael B. Stone, Arun Nagdev, Michael C. Murphy, Craig A. Sisson — 2009-10-26

Abstract: Introduction: Ultrasound guidance decreases complications of central venous catheter (CVC) placement, but risks of arterial puncture and inadvertent arterial catheter placement exist. Ultrasound-assisted detection of guidewire position in the internal jugular vein could predict correct catheter position before dilation and catheter placement.Methods: Ultrasound examinations were performed in an attempt to identify the guidewire before dilation and catheter insertion in 20 adult patients requiring CVC placement. Central venous pressures were measured after completion of the procedure.Results: Guidewires were visible within the lumen of the internal jugular vein in all subjects. Central venous pressures confirmed venous placement of catheters. Ultrasound visualization of the guidewire predicted venous CVC placement with 100% sensitivity (95% confidence interval 80-100%) and 100% specificity (95% confidence interval 80%-100%).Conclusions: Ultrasound reliably detects the guidewire during CVC placement and visualization of the wire before dilation and catheter insertion may provide an additional measure of safety during ultrasound-guided CVC placement.

Bajiaolian poisoning—a poisoning with high misdiagnostic rate

2009-10-21

Abstract: Background: One of the oldest Chinese herbal medicine, bajiaolian is widely used in traditional therapy. In Taiwan, bajiaolian is the fifth highest cause of poisoning among herbal medicines. The diagnosis is difficult because physicians are unfamiliar with this medicine's multiple presentations in different stages of intoxication.Procedures: The records of 4 major poison centers in Taiwan were searched for all bajiaolian intoxication from July 1985 (the opening of first poison center) to March 2003. Two emergency physicians with toxicologic training reviewed the admission charts and visited case patients for follow-up.Findings: Seventeen patients were identified, of which 15 (88.2%) had been misdiagnosed initially. In the beginning of their medical care, 14 cases were diagnosed as acute gastroenteritis.Conclusion: Bajiaolian intoxication is probably misdiagnosed because of early gastrointestinal symptoms followed by neurologic symptoms. A detailed patient history should be taken, and symptoms should be reviewed systemically to improve diagnostic accuracy.

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

2009-10-26

Abstract: Objective: The aim of the study was to evaluate use of physician assistants (PAs) and nurse practitioners (NPs) in US emergency departments (EDs).Methods: We analyzed visits from the 1993 to 2005 National Hospital Ambulatory Medical Care Survey, seen by midlevel provider (MLP), and compared characteristics of MLP visits to those seen by physicians only.Results: From 1993 to 2005, 5.2% (95% CI, 4.6%-5.8%) of US ED visits were seen by PAs and 1.7% (95% CI, 1.5%-2.0%) by NPs. During the study period, PA visits rose from 2.9% to 9.1%, whereas NP visits rose from 1.1% to 3.8% (both Ptrend < .001). Compared to physician only visits, those seen only by MLPs arrived by ambulance less frequently (6.0% vs 15%), had lower urgent acuity (37% vs 59%), and were admitted less often (3.0% vs 13%).Conclusions: Midlevel provider use has increased in US EDs. Their involvement in some urgent visits and those requiring admission suggests that the role of MLPs extends beyond minor presentations.

Termination of drug-induced torsades de pointes with overdrive pacing

2009-10-07

Abstract: Drug-induced prolongation of the QT interval is frequently encountered after medication overdose. Such toxicity can result in degeneration to torsades de pointes (TdP) and require overdrive pacing. We present 3 cases in which intentional medication overdose resulted in QTc prolongation with subsequent degeneration to TdP. Despite appropriate care, including magnesium therapy, each case required overdrive pacing for resolution of TdP. Although rarely encountered, patients with drug-induced TdP can be successfully managed with overdrive pacing.

Pyometra: a potentially lethal differential diagnosis in older women

2010-01-01

Pyometra is an uncommon disease, referring to accumulation of pus in the uterine cavity . It mostly occurs in postmenopausal women. The classic symptoms of pyometra (lower abdominal pain, purulent vaginal discharge, and enlarged uterus) are nonspecific and easily misdiagnosed as other causes of acute abdomen . We report 7 cases with pyometra during a 5-year period. Four cases were diagnosed as urinary tract infection (UTI) initially, and pyometra was diagnosed by imaging studies. All had favorable outcomes, but 1 died because of delayed diagnosis.

McKittrick-Wheelock syndrome: is it really rare?

2010-01-01

Secretory diarrhea and hypokalemia due to villous adenomas are known as the McKittrick-Wheelock syndrome. It was first described in 1954, by McKittrick and Wheelock as a carcinoma of the colon. We report 4 cases with this rare syndrome and want to draw attention to this question: is it really rare?

If you see the contusion, there is no pneumothorax

Gino Soldati, Sara Sher, Roberto Copetti — 2010-01-01

We evaluated with interest the data from the study of Platz et al recently published in the American Journal of Emergency Medicine. We agree with the high sensitivity attributed to chest ultrasonography in the diagnosis of pneumothorax (PNX), greater than that of chest radiography. We however disagree with the idea of a potential loss of accuracy toward diagnosis of PNX in case of pulmonary contusion. Furthermore, we consider incomplete an approach to an ultrasonographic diagnosis of PNX solely based on the presence or absence of lung sliding and that does not consider the presence of lung points (specific of PNX) or of comet tail artifacts (B-lines) . This latter sign, in particular, has the potential of being able to exclude PNX with 100% sensitivity, as B-lines actually originate from the visceral pleura.

Response to: “If you see the contusion, there is no pneumothorax”

Elke Platz, Rita Cydulka, Sandra Werner, Jessica Resnick, Robert Jones — 2010-01-01

We would like to thank the readers for their insightful comments. We agree that a combination of several sonographic findings and techniques, such as lung sliding, comet tails, lung point, M-mode, power Doppler, and others, may be needed to confidently rule out the presence of a pneumothorax. However, evaluating these combinations was not the objective of our study. Our study was designed to specifically evaluate whether lung sliding is affected by the presence of pulmonary contusions. This question is of interest because many clinicians consider lung sliding the mainstay of the sonographic evaluation of pneumothorax. The clinical problem was briefly addressed by Blaivas and colleagues in 2005, which raised the concern that the presence of pulmonary contusions may affect lung sliding and limit the usefulness of ultrasound to exclude a pneumothorax under these circumstances.

Issues on percutaneous feeding tube replacement

Vui Heng Chong — 2010-01-01

I read with interest the publication by Jacobson et al in the recent issue of the journal on confirmatory radiography post-percutaneous feeding tube (PFT) replacement. They highlighted 2 important issues on PFT replacement; the role of radiography and the importance of tract trauma. Overall, they did not show any impact of routine post replacement radiography. Like many other centers, we do not use radiography at all. In our setting, the only time radiography had been used post PFT replacement, tube misplacement was missed. This patient had a balloon-type PFT replacement done in the emergency department and injected contrast was seen entering the small bowel. The position was reported to be correct. It turned out that the balloon part had been inserted through the pylorus resulting in gastric outlet obstruction . Currently, there is still no convincing evidence in the literature to support the routine use of radiography. The second issue highlighted, in my opinion, is more relevant. It would be more prudent to avoid further trauma to the already traumatized tract by avoiding repeated manipulation and dilatation of the tract, especially the immature tracts. In Jacobson's study, most of their patients had tract trauma secondary to accidental PFT extraction and 10% of their patients had tract dilatation. In the 4 complicated cases, risk factors for tract disruptions were present, including 3 immature tracts. In my practice, I usually assess the tract for possibility of immediate replacement with the intended PFT (Cook 24F balloon replacement PEG). If the tract is immature or has narrowed because of late presentations, I would recommend placing a small urinary catheter (12F-18F) into the stomach. The catheter will serve as a temporary feeding tube and a dilator. The catheter can be replaced with larger catheter and this can be done within hours to weeks. After 2 to 3 exchanges, the tract usually will have opened up to allow easy placement of a 24F PFT (24F). To date, we have not encountered any problems with this practice. Therefore, it is probably more important and cost-effective to avoid further trauma that may result in complication. Finally, there were many other important details that were not presented that might be important in the understanding the true impact of PFT replacement with or without radiography. Details on the types of displaced PFT (balloon or mushroom type internal bolster), details on level of difficulty with replacement, the number of attempts required, sizes of the replacement PFT used, and the level of expertise of those who did the replacement are all important.

Intraperitoneal versus retroperitoneal air signs in abdominal radiographs

Yen-Chieh Wang, Chih-Ming Lin, Shao-Kuan Chen — 2010-01-01

Free air demonstrated in supine abdominal radiographs (kidneys, ureters, bladder, or KUB) always suggest potential life-threatening illnesses, yet it is usually overlooked by physicians in modern times. We read with great interest the article of Chiu et al , which analyzed in details a variety of intraperitoneal free air signs of hollow organ perforation on many of supine KUB in a recent issue of The American Journal of Emergency Medicine. The authors categorized 4 subgroups of free air signs, including bowel-related, right upper quadrant, peritoneal ligament-related, and other signs; thus, readers are able to learn these classic features systemically through this article. However, the retroperitoneal air signs in KUB, also indicating lethally retroperitoneal hollow organ perforation or infection, were not mentioned in this article. We report here a patient with concurrent intraperitoneal and retroperitoneal air signs in supine KUB and emphasize the importance of the implication of retroperitoneal air sign.

First report of hypoglycemia secondary to dandelion (Taraxacum officinale) ingestion

Erkan Goksu, Cenker Eken, Ozgur Karadeniz, Oguz Kucukyilmaz — 2009-11-23

Consumption of herbal remedies has become prevalent throughout the world and can be found easily over the counter. Many times, these are exempt from safety controls, and the consumption may cause adverse effects and complications. In this letter, we present a case of hypoglycemia due to the ingestion of dandelion.

Celiac artery dissection presenting with abdominal and chest pain

Jian-Liung Wang, Ming-Jer Hsieh, Cheng-Hung Lee, Chun-Chi Chen, I-Chang Hsieh — 2009-11-23

Spontaneous dissection of the celiac artery is uncommon and is rarely considered in patients with acute abdomen. However, this condition has been reported frequently in recent years. Subjects are predominantly male and younger than 50 years. Mortality is reportedly high if dissection extends to the hepatic artery and warranted operative or endovascular treatment. Conservative treatment is justified in patients with isolated celiac dissection without bowel ischemia or hemorrhage. This report describes a male patient with celiac dissection presenting with left upper abdomen and chest pain, which subsided after conservative treatment with antihypertensive agents.

Stercoral perforation of colon: a rare but important mimicker of acute appendicitis

Tien-Fa Hsiao, Yenn-Hwei Chou — 2009-11-23

Stercoral perforation of colon is an extremely rare but life-threatening cause of acute abdomen. Typically, the clinical manifestation is generalized peritonitis, and the diagnosis was made only at laparotomy. This report concerns an illustrative case of stercoral perforation of sigmoid colon that mimicked acute appendicitis, and correct diagnosis was established preoperatively by computed tomography.

Negative pressure pulmonary hemorrhage induced by a candy

Gian Luca Casoni, Sara Tomassetti, Angelo Coffa, Claudia Ravaglia, Venerino Pol — 2010-01-01

Negative pressure pulmonary edema, a well-recognized phenomenon, is the formation of pulmonary edema after an acute upper airway obstruction, but pulmonary hemorrhage associated with negative-pressure pulmonary edema is rare. Vigorous inspiratory efforts against an obstructed upper airway (the modified Mueller maneuver) led to the development of acute negative-pressure pulmonary edema. We describe a case of negative pressure pulmonary hemorrhage induced by a candy. The patient required short-term ventilation with continuous positive airway pressure (12 cm H2O) by face mask with rapid resolution of clinical and radiological findings. Negative pressure pulmonary edema may present as pulmonary hemorrhage and require positive-pressure ventilatory support for some time. The mechanism for pulmonary hemorrhage associated with negative pressure pulmonary edema is not clear, but disruption of the alveolar-capillary membrane caused by large negative pressure swings is most likely.

Successful treatment of traumatic coronary artery dissection with angiographic stenting

Yin-Chun Chang, Chih-Hsien Wang, Yin-Yi Han, Wen-Je Ko, Yung-Chie Lee — 2010-01-01

Coronary artery injury after blunt chest injury is rare, and traumatic coronary artery dissection is even rarer. A 24-year-old man, who had previously been healthy without risk factors for coronary artery disease, had a motorcycle accident resulting in mandible and left femoral shaft fractures, with only minor chest wall contusion. Operations for interdental wiring of the mandible, left femoral shaft open reduction, and internal fixation with interlocking nails were performed on the third day. Arterial desaturation was noted immediately after extubation in the operation room. The patient was reintubated and transferred to the intensive care unit for further care. An electrocardiogram showed sinus tachycardia and Q wave in precordial leads. A chest x-ray film showed bilateral lung edema, and the laboratory data revealed positive cardiac markers with a creatine kinase/creatine kinase-MB isoenzyme level of 6510/95 U/L and troponin I greater than 40 ng/mL. Echocardiography showed a left ventricle regional wall motion abnormality with a left ventricular ejection fraction of 38%. A thallium heart scan revealed mixed viable and nonviable myocardium at mid to basal inferior and septal walls, a transmural scar at the apex, and anterior and apical inferior walls. Coronary angiography showed dissection from the distal left main coronary artery to the proximal left anterior descending coronary artery. We performed percutaneous occlusive balloon angioplasty and stenting with satisfactory results.

Severe reaction to inadvertent intravenous administration of a large dose of norepinephrine

2010-01-01

We report the first case ever published of norepinephrine overdose. A 43-year-old female patient admitted in the emergency department for abdominal pain inadvertently received an intravenous bolus injection of 16 mg norepinephrine instead of the scheduled antispasmodic drug phloroglucinol. She immediately experienced severe tachycardia, hypertensive crisis, peripheral vasoconstriction, and acute cardiac ischemia. Although the initial symptoms subsided within a few minutes, the patient subsequently developed hypotension, severe pulmonary edema, and right cardiac failure. Symptomatic treatment resulted in complete recovery. The clinical pattern was similar to epinephrine overdose as previously described in the literature. Indeed, although norepinephrine and epinephrine exert different agonistic properties on α- and β-adrenergic receptors due to dissimilar receptor binding, these differences tend to diminish when high doses of either catecholamine are administered.

Adult Still disease: worsening inflammatory changes in a 26-year-old woman

Daniel Jimenez, Paul Allegretti, Kathy Kallal — 2010-01-01

Adult Still disease is a rare inflammatory disorder affecting approximately 2 per million per year. This disorder is characterized by daily spiking fevers, arthritis, and a rash. Early recognition, diagnosis, and treatment can reduce the possibility of long-term complications as well as potentially life-threatening organ damage. Because there are no specific tests available to make the diagnosis of Adult Still disease, a thorough understanding of the specific diagnostic criteria as well as a good physical examination is crucial in making the correct diagnosis. We report a case of a young female whose diagnosis was delayed until the third physician visit presumably because of unfamiliarity of the disease process.

Ischemic stroke in trauma patients: investigating the source of embolus

Nurettin Özgür Doğan, Erkan Temizkan, Fikret Bildik, Ahmet Demircan, Ayfer Keleş — 2010-01-01

Motor vehicle crash victims presenting with ischemic stroke are rare in emergency departments when compared with victims of accidents resulting in intracranial hemorrhagical events. Moreover, traumatic internal carotid artery dissection, which is an important cause of ischemic stroke in motor vehicle trauma patients, is a complication of severe blunt head or neck trauma. We report 2 cases presenting with cerebral infarction after experiencing motor vehicle trauma, which were caused by traumatic carotid artery injuries and managed by different strategies.

Hypothermia with extracorporeal membrane oxygenation for sudden cardiac death and submersion

2010-01-01

A case of successful recovery from cardiopulmonary arrest and submersion is reported. The victim collapsed due to ventricular fibrillation owing to acute coronary syndrome with double coronary vessel occlusion and was found nearly drowned in a hot bathtub. Although he was resuscitated, he had been hypoxic because of aspiration. Two hours after return of spontaneous circulation, he was transferred to our institution with hypoxia. No attempt of cerebral protection was done before admission. Therapeutic hypothermia was initiated with a veno-venous extracorporeal membrane oxygenation system by direct cooling of circulating blood. Not only effective oxygenation but also accurate control of the body temperature during 5 days of hypothermia were obtained. In addition, coronary bailout was successfully performed under hypothermia. After 3 weeks of intensive care, he regained consciousness and presented with complete neurologic recovery. Despite delayed initiation of more than 2 hours, therapeutic hypothermia with veno-venous extracorporeal membrane oxygenation was effective for cerebral protection in a case of cardiopulmonary arrest with subsequent submersion.

Primary torsion of omentum: a rare cause of acute abdomen

2010-01-01

In this study, a rare case of primary omental torsion was reported. A 20-year-old man presented with right lower quadrant pain and nausea. Physical examination revealed abdominal tenderness in the right iliac fossa, but muscular rigidity was not found. Increased white blood cell count (23,400/mL) was noted in the whole blood count. The patient underwent laparotomy with an initial diagnosis of acute appendicitis. The abdominal exploration revealed a normal appendix and infarcted omentum secondary to torsion on the long axis. The torted and necrotic omentum was resected, and the patient was discharged uneventfully at postoperative second day. Omental tortion should be considered as a possible diagnosis especially when the appendix does not explain the patient's symptoms during the abdominal exploration.

Major ST-segment elevation hiding acute severe pancreatitis

2010-01-01

A 78-year-old woman presented with abdominal pain in a suspicion of ethanol intoxication. Baseline 12-lead electrocardiogram showed a major ST-segment elevation suggestive of an acute myocardial infarction. Troponin I was 6.6 ng/mL. Transthoracic echocardiography found normal left ventricular ejection fraction, with no wall motion abnormality or pericardial effusion. Then, amylase and lipase serum levels were 1199 and 3873 IU, respectively, and primary coronary angiography was cancelled. At 48 hours, abdominal CT scan confirmed the diagnosis of severe acute pancreatitis. At 8 days, electrocardiogram showed inverted T waves without Q wave. Delayed cardiac magnetic resonance imaging showed no signs of myocarditis or ischemic sequelae, normal segmental wall motion, and preserved left ventricular ejection fraction (70%). Coronary angiography was also normal.

Management of foreign body in esophagus with rigid bronchoscopy

Luciano Delgado-Plasencia, Nuria Manes-Bonet, Esther Torres Monzón — 2010-01-01

Ingestion of a sharp foreign body can lead to esophageal perforation that is related with high comorbidity. To avoid such complications, early and adequate management of these cases is essential. Currently, the most commonly used extraction technique is endoscopy.

Intravenous thrombolysis in a patient with known cavernous malformation: a first case report

Nils Henninger, Nabil Ahmad, Jane G. Morris — 2010-01-01

Abstract The presence of a cerebral cavernous malformation (CM) is generally not regarded as an exclusion criterion to the use of intravenous tissue plasminogen activator (tPA). However, there is a conceivable risk of hemorrhaging with an intracerebral CM, which may dissuade clinicians from treating stroke patients with systemic tPA in the presence of a CM. The case of a 79-year-old man with acute ischemic stroke treated with systemic tPA in the setting of known CM is presented. The patient tolerated intravenous thrombolysis well and remained clinically stable throughout the observation period. This is the first reported case (to our knowledge) supporting the notion that systemic thrombolysis is safe in presence of a previously clinically silent CM.

Rapid diagnosis of jejunojejunal intussusception by an emergency physician–performed bedside ultrasound

Kuo-Chih Chen, Tzu-Yao Hung, Te-Hao Wang, Tzong-Luen Wang, Chee-Fah Chong — 2010-01-01

The clinical symptoms of adult intussusception are often vague and nonspecific. As a result, its diagnosis is frequently delayed in most cases. Ultrasound is well recognized as an important adjunct in the diagnosis of pediatric intussusception. However, its utility in the detection of adult intussusception is not well established. We report a 79-year-old man who presented to the emergency department with epigastric pain and bilious vomiting for 2 days. Shortly after his arrival, the diagnosis of jejunojejunal intussusception was made with bedside ultrasound performed by the emergency physician. The case demonstrated that early diagnosis of adult intussusceptions in the emergency department is possible by using a bedside ultrasound.

Actinomycosis osteomylelitis of the mandible

Allison M. Finley, Michael S. Beeson — 2010-01-01

A 44-year-old man presented to the emergency department with jaw pain and swelling. He was found to have osteomyelitis of the mandible caused by Actinomyces species. Although rare, actinomycosis of the head and neck is treatable and curable and should not be forgotten on the differential diagnosis list in the typical patient population with appropriate symptoms.

Acute gastric volvulus: a rare but real surgical emergency

Meng-Huan Wu, Yu-Che Chang, Cheng-Hsien Wu, Shih-Ching Kang, Jen-Tse Kuan — 2010-01-01

Acute gastric volvulus is a rare disease that requires a high index of suspicion for diagnosis and rapid treatment. Many cases occur with a paraesophageal hernia or diaphragmatic eventration. It is potentially life threatening because delayed diagnosis and treatment may result in perforation, infarction, and other lethal results. The signs and symptoms of acute gastric volvulus include abdominal pain and distention, especially in the upper abdomen, and vomiting with progression to nonproductive retching. Because of the rarity of this disease, common gastrointestinal complaints may mislead the emergency department (ED) physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examination are not obtained. Traditionally, it is diagnosed by seeing intrathoracic viscera in the chest radiograph, followed by a barium contrast study or upper gastrointestinal endoscopy. Currently, computed tomography allows an immediate diagnosis with all the anatomical details. The whirl sign, which is an important characteristic of gastrointestinal volvulus, is rarely seen on computed tomography in gastric volvulus. Acute gastric volvulus is regarded as a surgical emergency, requiring either open or laparoscopic surgery. We report a case of acute gastric volvulus secondary to a paraesophageal hernia that presented with acute abdominal pain and fullness and had an unfavorable outcome. This should remind all ED physicians to maintain a high index of suspicion for this disease when treating patients with acute abdominal pain and to seek immediate surgical intervention once diagnosed.

Medial wall fracture- induced pneumo-orbita mimicking inferior rectus entrapment

Benjamin Burt, Michael Jamieson, Brian Sloan — 2010-01-01

Abstract: The authors report 2 patients who experienced medial wall blowout fractures. Both patients presented with significant restriction of upgaze, mild proptosis, and crepitus of the upper lid. Computed tomography revealed significant pneumo-orbita filling the superior orbit with inferior displacement of the muscle cone and subcutaneous emphysema. No floor fractures were seen in either patient, but in both cases, the medial wall was breached and was almost certainly the source of the intraorbital air. Patients were managed conservatively, and the vertical gaze deficiencies resolved after 3 to 5 days. Large amounts of intraorbital and extraorbital air in the absence of a floor fracture can imitate inferior rectus entrapment and could potentially lead to unnecessary surgical intervention.

Axillary artery transection after recurrent anterior shoulder dislocation

2010-01-01

Abstract: Axillary artery transection after recurrent anterior shoulder dislocation is extremely rare. We present 2 such patients. The first, a 62-year-old man, presented with acute ischemia and a large hematoma in the axilla and chest wall. The second, a 63-year-old man, had a pseudoaneurysm and palpable peripheral pulses. Both underwent urgent computed tomography, which confirmed the clinical diagnosis, and the patients were taken to the operating room. In the first patient, intraoperative angiogram through both the brachial and the femoral route showed complete disruption of the axillary artery rendering an endovascular approach not possible. Proximal balloon occlusion was then undertaken through the femoral artery, controlling the bleeding and allowing easier dissection of the ruptured segment. Revascularization was performed with an interposition polytetrafluoroethylene (PTFE) bypass restoring normal blood supply to the upper extremity. The second patient had a Viabhan (W.L. Gore, Flagstaff, Ariz) stent-graft implanted through the brachial artery with an excellent clinical and angiographic result. As expected, both patients had significant neurologic morbidity due to associated brachial plexus palsy. Ruptured axillary artery after shoulder dislocation is very uncommon. Endovascular repair and hybrid procedures combining open and endovascular techniques can offer reliable solutions to these challenging problems.

Assessing response to changing plasma/red cell ratios in a bleeding trauma patient

2010-01-01

Abstract: Recent military experience suggests that transfusing fresh frozen plasma and packed red cells in a 1:1 ratio may improve survival in exsanguinating trauma patients. We report the case of a single patient who required massive transfusion after suffering a single gunshot wound. Initially, the patient received FFP:PRBC in 1:2 ratio, but this did not correct laboratory parameters except for INR and clotting factor VII level, which were likely normalized by treatment with recombinant activated factor VII. After receiving FFP:PRBC in a 4:5 ratio, he continued to bleed and his coagulation profile showed no appreciable improvement. In the final phase, he received FFP:PRBC in a 7:5 ratio and his laboratory parameters of coagulopathy normalized, except for factor V level which was improved. He also clinically stopped bleeding.

Soccer player whiplash maculopathy

Claire Uebbing, Joseph Miller, Clifford Arnold, Mark Walsh — 2010-01-01

A 17-year-old girl experienced a head-to-head collision on the soccer field and presented several hours later with central vision loss. Eye examination findings revealed macular edema consistent with whiplash maculopathy. Symptom resolution required 3 months with no intervention necessary. Whiplash maculopathy is a little-known disease pathology in which the proposed mechanism of action involves traction on the eye's vitreous base. Rapid acceleration and deceleration forces cause focal areas of detachment at the retinal pigment epithelial junction and thus result in visual loss.

Dimerized plasmin fragment D: a reliable biomarker for diagnosing aortic dissection?

Chien-Hao Lin, Shyr-Chyr Chen, Wen-Jone Chen, Chien-Hua Huang — 2010-01-01

Acute aortic dissection (AAD) is an important differential diagnosis in the early management of acute chest pain syndrome. Early recognition and treatment are crucial and will lead to a better survival. However, bedside evaluations including the symptoms, signs, or laboratory tests are all not sensitive [Arch Intern Med. 2000; 160(19):2977-2982]. Advanced diagnostic tools, such as contrast-enhanced computed tomography, transesophageal echocardiography, and magnetic resonance imaging, are usually time- and cost-consuming and not readily available in the emergency department [Arch Intern Med. 2006;166(13):1350-1356]. In recent years, the dimerized plasmin fragment D (d-dimer) test has been largely reported as a useful diagnostic biomarker with 100% sensitivity in AAD [J Am Coll Cardiol. 2004;44(4):804-809; Acad Emerg Med. 2004;11(4):397-400; Circulation. 2004;109(3):E24; Chest. 2003;123(5):1375-1378], and it was proposed to be a reliable tool in exclusion of AAD. However, its reliability in clinical practice remains inconclusive. Here, we present a case of type I acute aortic dissection without positive d-dimer test result. The d-dimer test can be a useful tool in initial evaluation of acute chest pain syndrome. However, the diagnosis of aortic dissection cannot be excluded by using only a negative d-dimer test result. A high clinical index of suspicion is still the key for accurate and timely diagnosis.

Leukocoria and irregular pupil

Jennifer L. Wiler, Christina Price, David R. Fintak, Carol Shields — 2010-01-01

Early detection and recognition of retinoblastoma, a rare but life-threatening malignancy, are strongly correlated with increased patient survival. Therefore, it is important for the emergency physician to recognize this condition.

Editorial Board

2010-01-01

Information for Authors

2010-01-01

American Journal of Emergency Medicine

Masthead

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access

Oral N-acetylcysteine has a deleterious effect in acute iron intoxication in rats

Diagnostic utility of the genital Gram stain in ED patients

Patients with coronary disease fail observation status at higher rates than patients without coronary disease

ED antibiotic use for acute respiratory illnesses since pneumonia performance measure inception

How stylet use can effect confirmation of endotracheal tube position using ultrasound

Can hypertonic saline influence platelet P selectin expression and platelet-leukocyte aggregation?

Validating the ABCD2 Score for predicting stroke risk after transient ischemic attack in the ED

Echocardiographic evaluation of TASER X26 probe deployment into the chests of human volunteers

Demographics of patient visits during high daily census in a pediatric ED

S-100β and neuron-specific enolase levels in carbon monoxide–related brain injury

Alcohol, bicycling, and head and brain injury: a study of impaired cyclists' riding patterns R1

Computed tomographic screening for thoracic and lumbar fractures: is spine reformatting necessary?

Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures

Ultrasound detection of guidewire position during central venous catheterization

Bajiaolian poisoning—a poisoning with high misdiagnostic rate

Use of midlevel providers in US EDs, 1993 to 2005: implications for the workforce

Termination of drug-induced torsades de pointes with overdrive pacing

Pyometra: a potentially lethal differential diagnosis in older women

McKittrick-Wheelock syndrome: is it really rare?

If you see the contusion, there is no pneumothorax

Response to: “If you see the contusion, there is no pneumothorax”

Issues on percutaneous feeding tube replacement

Intraperitoneal versus retroperitoneal air signs in abdominal radiographs

First report of hypoglycemia secondary to dandelion (Taraxacum officinale) ingestion

Celiac artery dissection presenting with abdominal and chest pain

Stercoral perforation of colon: a rare but important mimicker of acute appendicitis

Negative pressure pulmonary hemorrhage induced by a candy

Successful treatment of traumatic coronary artery dissection with angiographic stenting

Severe reaction to inadvertent intravenous administration of a large dose of norepinephrine

Adult Still disease: worsening inflammatory changes in a 26-year-old woman

Ischemic stroke in trauma patients: investigating the source of embolus

Hypothermia with extracorporeal membrane oxygenation for sudden cardiac death and submersion

Primary torsion of omentum: a rare cause of acute abdomen

Major ST-segment elevation hiding acute severe pancreatitis

Management of foreign body in esophagus with rigid bronchoscopy

Intravenous thrombolysis in a patient with known cavernous malformation: a first case report

Rapid diagnosis of jejunojejunal intussusception by an emergency physician–performed bedside ultrasound

Actinomycosis osteomylelitis of the mandible

Acute gastric volvulus: a rare but real surgical emergency

Medial wall fracture- induced pneumo-orbita mimicking inferior rectus entrapment

Axillary artery transection after recurrent anterior shoulder dislocation

Assessing response to changing plasma/red cell ratios in a bleeding trauma patient

Soccer player whiplash maculopathy

Dimerized plasmin fragment D: a reliable biomarker for diagnosing aortic dissection?

Leukocoria and irregular pupil

Editorial Board

Contents

Information for Authors