Cases reported "Emergencies"

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1/48. Traumatic fracture of the hyoid bone: three case presentations of cardiorespiratory compromise secondary to missed diagnosis.

    hyoid bone fractures secondary to blunt trauma other than strangulation are rare (ML Bagnoli et al., J Oral Maxillofac Surg 1988; 46: 326-8), accounting for only 0.002 per cent of all fractures. The world literature reports only 21 cases. Surgical intervention involves airway management, treatment of associated pharyngeal perforations, and management of painful symptomatology. The importance of hyoid fracture, however, rests not with the rarity of it, but with the lethal potential of missed diagnosis. We submit three cases with varying presentations and management strategies. All three of our cases incurred injury by blunt trauma to the anterior neck. Two patients required emergent surgical airway after unsuccessful attempts at endotracheal intubation. One patient presented without respiratory distress and was managed conservatively. After fracture, the occult compressive forces of hematoma formation and soft tissue swelling may compromise airway patency. It is our clinical observation that hypoxia develops rapidly and without warning, leading to cardiorespiratory collapse. With endotracheal intubation prohibited by obstruction, a surgical airway must be established and maintained. Recognition of subtle clinical and physical findings are critical to the diagnosis of laryngotracheal complex injuries and may be life-saving in many instances. To ensure a positive outcome, a strong degree of suspicion based on mechanism of injury is mandated.
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2/48. Cranial arteritis: a medical emergency with orofacial manifestations.

    BACKGROUND: Cranial arteritis, or CA, a vascular disease affecting primarily elderly people, may result in permanent blindness if untreated. Since it frequently mimics temporomandibular joint, myofascial or odontogenic pain, dentists must be familiar with this condition. CASE DESCRIPTION: The authors present reports of two patients who had signs and symptoms of CA, some of which were suggestive of other head and neck pain disorders. In both cases, the diagnosis of CA was confirmed by temporal artery biopsy, and treatment with systemic steroids resulted in rapid resolution of symptoms. CLINICAL IMPLICATIONS: Prompt diagnosis and treatment of CA not only results in resolution of symptoms, but also may prevent blindness, the most serious sequela of the condition.
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3/48. The acute diagnosis of Takayasu's arteritis based on helical CT angiography of the chest and neck in the emergency room.

    Recently, a young woman presented acutely with a left hemispheric stroke and differing blood pressures in the arms as her initial manifestation of Takayasu's arteritis. Helical CT angiography, performed to rule out aortic dissection, revealed a thickened wall of the aortic arch with stenoses and occlusions of the great vessels, suggesting the diagnosis. The sequence of imaging studies and findings in this unusually catastrophic presentation of a typically insidious disease are highlighted.
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4/48. Glossopharyngeal and neck accessory muscle breathing in a young adult with C2 complete tetraplegia resulting in ventilator dependency.

    BACKGROUND AND PURPOSE: This case report describes the use of glossopharyngeal breathing (GPB) and neck accessory muscle breathing (NAMB) in the treatment of an individual who was dependent on a ventilator secondary to a spinal cord injury. CASE DESCRIPTION: The patient was a 19-year-old man with C2 complete tetraplegia. He received a 5-week inpatient program of GPB training 3 to 4 times per week. A 4-week NAMB training program followed. OUTCOME: Following GPB training, forced vital capacity increased 35-fold, time off the ventilator improved from 0 to 30 minutes, and a nonfunctional cough became a weak functional cough. After NAMB training, the patient was able to be off the ventilator for 2 minutes. DISCUSSION: Increased ventilatory capability has the potential to affect patients' quality of life by improving cough function and decreasing dependence on a ventilator in the event of accidental disconnection.
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5/48. The lateral soft tissue neck X-ray in accident and emergency medicine.

    Five patients with upper aerodigestive tract pathology seen acutely in the Accident and Emergency department at St Mary's Hospital, london are presented. The value of the lateral soft tissue neck X-ray in their diagnosis is discussed.
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6/48. Traumatic dissection of the internal carotid artery.

    We present the case of an 11-year-old male who had a dissection of his left internal carotid artery following a rather innocuous mechanism of injury. Although this phenomenon is documented in the medical literature, it remains a relatively rare event following blunt injury to the head and neck (0.3% occurrence rate in 1 study spanning 7 years). (Despite its rarity, it remains an important cause of cerebrovascular accidents in children. 2) Children presenting with gross neurologic abnormalities following blunt trauma to the head or neck should be considered to have sustained injury to the carotid arteries until proven otherwise.
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7/48. Tracheal agenesis in newborns.

    OBJECTIVES/HYPOTHESIS: A series of three newborns with tracheal agenesis is described. The preferred methods of diagnosis, description of the clinical course, and a review of the pertinent embryology, associated anomalies, and clinical management are presented. STUDY DESIGN: A retrospective study of a clinical series of referred patients from 2002 to 2003 who were seen at a single institution. methods: Chart review for clinical course and pathological specimens was performed in all cases. Three patients were identified with tracheal agenesis. RESULTS: All three newborns died within 48 hours of birth. All of the children underwent emergency laryngoscopy and neck exploration. Gross and microscopic pathological examination was accomplished on all patients. CONCLUSION: Although tracheal agenesis is rare, it may be more common than previously thought. The diagnosis is not straightforward, and the prognosis is grim. The embryology of the trachea and other foregut derivatives is closely related, and associated birth defects are common.
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8/48. burns and tracheo-oesophageal-cutaneous fistula.

    We report an unusual case of electric burns suffered by a 15-yr-old boy. The patient's neck had come in contact with a high voltage broken electric wire and by reflex he had pulled it away with his right hand. He presented with a tracheo-cutaneous fistula with a right-sided pneumothorax. Emergency airway management included insertion of a tracheostomy tube through the traumatic opening in the neck and insertion of an intercostal tube drain. When the diagnostic endoscopy revealed an externally communicating tracheo-oesophageal fistula, protecting the lower airways from gastrointestinal contamination became a priority. The patient was anaesthetized through the traumatic tracheostomy and a formal low tracheostomy was done below the level of the fistula. The patient then underwent oesophageal reconstruction with a stomach free flap. Tracheo-oesophageal-cutaneous fistula is a rare presentation of electric burns. The anaesthetic management of the emergency difficult airway in any penetrating neck injury can be extremely difficult requiring a carefully planned multi-disciplinary approach.
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9/48. Descending necrotising mediastinitis: a report of misdiagnosis as thoracic aortic dissection.

    Descending necrotising mediastinitis is an uncommon disease in the emergency department. Early recognition is important for a good prognosis for this fatal condition. This report describes a case of a healthy 79 year old woman who was seen in the urgent care centre with the initial presentation of chest pain. Misdiagnosis was made because of the mis-reading of a flap-like artefact over the ascending aorta and difficulty interpreting subtle change of mediastinal soft tissue infiltration. The patient was then treated as dissecting aneurysm over ascending aorta until her condition deteriorated. Although aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics were begun, the response was poor. Emergency physicians should be familiar with this rare but highly lethal disease. Correlation should be made in a patient complaining about chest pain, especially combined with fever, sore throat, dysphagia, or neck swelling.
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10/48. Rattlesnake envenomation to the face of an infant.

    BACKGROUND: mortality from rattlesnake envenomation in the united states is rare. Despite approximately 8000 crotaline (pit vipers) bites annually, it is estimated that only 10 to 15 deaths occur. Besides direct intravascular envenomation and anaphylaxis, bites to the head and neck may account for some of these rare fatalities. We report a pediatric case of severe facial envenomation requiring emergent intubation and antivenom administration. CASE REPORT: A 14-month-old female toddler was envenomated by a Southern Pacific rattlesnake (crotalus viridis helleri) above the right upper lip while playing in her backyard. Rapid swelling and ecchymosis developed, and the patient was airlifted to a pediatric tertiary care hospital. Within 3 hours, stridorous respirations complicated by significant facial and oropharyngeal edema necessitated emergent orotracheal intubation. A total of 16 vials of FabAV [Crotalidae Polyvalent Immune Fab (ovine) antivenom] were administered over the next 24 hours. The child gradually improved and was successfully extubated 5 days later. A 3-month follow-up demonstrated no significant cosmetic facial abnormalities. CONCLUSION: Crotaline bites to the head and neck have the potential for significant swelling and airway compromise. Facial bites, anaphylaxis, and rare intravascular envenomation may account for many of the fatalities from rattlesnake envenomation. Early intubation may be required to maintain airway patency.
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