Cases reported "Emergencies"

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1/39. The portable Doppler: practical applications in EMS care.

    The practical application of a new, commercially available, portable Doppler ultrasound device to the operation of a busy city-county emergency department and ambulance service was investigated. An initial evaluation using healthy volunteers confirmed accuracy and reproducibility of the Doppler blood pressure readings comparable to that of auscultatory and palpatory measurement. In selected patients, the Doppler readings correlated well with readings from patients who had intra-arterial lines. When used in several low flow states, such as testing adequacy of cardiopulmonary resuscitation (CPR) and verification of electromechanical dissociation, the Doppler aided the clinical evaluation and treatment in many cases where traditional methods were useless. The Doppler was also helpful in the evaluation of local arterial injury but this unit was not found sensitive enough for venous disease. Finally, the Doppler enhanced the obtaining of vital signs in the noisy environment of our ambulances.
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2/39. Alkaptonuric aortic stenosis: a case report.

    alkaptonuria is a rare disease of phenylalanine, aromatic amino acids, and tyrosine metabolism. Because of a genetic deficiency of the enzyme homogentisic acid oxidase, an accumulation of homogentisic acid causes ochronotic pigment deposition. The most common clinical manifestations are arthropathy, urinary calculi and discoloration, cutaneous and cartilaginous pigmentation, and cardiac valvular disease. Arthropathy and aortic stenosis are the most debilitating manifestations of the disease. A case of alkaptonuric aortic stenosis is described. A 75-year-old woman with a history of alkaptonuria presented in the emergency department with complaints of progressive dyspnea. Upon examination, the patient was hypertensive, tachypneic, and tachycardic with premature ventricular contractions. She had pitting edema of the lower extremities and complaints of generalized weakness. Chest x-rays revealed congestive heart failure and pulmonary edema. diuretics were administered, and a continuous nitroglycerin infusion was initiated in the emergency department. The patient was admitted for further evaluation. The patient's respiratory status continued to decline. She was intubated endotracheally 1 day after admission. Subsequent cardiac evaluation revealed an ejection fraction of 35%, severe aortic stenosis, mild coronary artery disease, ischemic cardiomyopathy, and anteroapical akinesis. A dobutamine infusion was instituted for persistent hypotension, and renal dose dopamine was initiated for oliguric renal failure. The patient underwent an emergency operation for an aortic valve replacement with a Dacron patch 10 days after admission. cardiopulmonary bypass and mild hypothermia were used during the procedure. The patient's hemodynamic status remained tenuous throughout the procedure. Although the first attempt to wean off cardiopulmonary bypass failed, the second attempt was successful with the aid of an intra-aortic balloon pump, inotropic support, and atrioventricular pacing. These measures were maintained during transport to the surgical intensive care unit. In the intensive care unit, the patient did not have an audible blood pressure or a palpable pulse without the support of the intra-aortic balloon pump and atrioventricular pacing. Coarse atrial fibrillation was the underlying electrocardiogram rhythm in the absence of atrioventricular pacing. sodium bicarbonate was given without improvement. After discussion with the family, all life support measures were discontinued. The patient died 10 minutes after her arrival in the intensive care unit. alkaptonuria's pathogenesis is manifested as both local and systemic in nature. collagen vascular diseases share a similar pattern of multisystem involvement. Despite the negative outcome for the patient described, valuable insight can be obtained by studying this case and noting the anesthetic considerations specific to collagen vascular diseases in general.
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3/39. Outcome of twin pregnancies in patients with haemoglobinopathies--case reports.

    pregnancy in patients with haemoglobinopathy is associated with increased risk of maternal and perinatal morbidities and mortalities. Multiple pregnancy is potentially more hazardous than singleton pregnancy. There is a dearth of information concerning multiple pregnancies in patients with haemoglobinopathy. Four of such patients seen in the obstetric service of the University College Hospital, Ibadan are presented here and discussed. Increased surveillance and elective caesarean delivery are suggested in the management of these patients.
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4/39. Successful resuscitation of a verapamil-intoxicated patient with percutaneous cardiopulmonary bypass.

    OBJECTIVE: To describe our experience with the use of percutaneous cardiopulmonary bypass as a therapy for cardiac arrest in an adult patient intoxicated with verapamil. DESIGN: Case report. SETTING: Emergency department of a university hospital. PATIENT: A patient with cardiac arrest after severe verapamil intoxication. INTERVENTIONS: Percutaneous cardiopulmonary bypass and theophylline therapy. CASE REPORT: A 41-yr-old white male had taken 4800-6400 mg of verapamil in a suicide attempt. On arrival of the ambulance physician, the patient was conscious with weak palpable pulses and was transported to a nearby hospital. The patient developed a pulseless electrical activity, and cardiopulmonary resuscitation was started. Despite all advanced life support efforts, the patient remained in cardiac arrest. Therefore, he was transferred under ongoing cardiopulmonary resuscitation to our department, where percutaneous cardiopulmonary bypass was initiated immediately (2.5 hrs after cardiac arrest). The first verapamil serum concentration obtained at admittance to our institution was 630 ng/mL. After several ineffective intravenous epinephrine applications, the administration of 0.48 g of theophylline as an intravenous bolus 6 hrs and 18 mins after cardiac arrest led to the return of spontaneous circulation. The patient remained stable and was transferred to an intensive care unit the same day. He woke up on the 12th day and was extubated on the 18th day. After transfer to a neuropsychiatric rehabilitation hospital, he recovered totally. CONCLUSION: In patients with cardiac arrest attributable to massive verapamil overdose, percutaneous extracorporeal cardiopulmonary bypass can provide adequate tissue perfusion and sufficient cerebral oxygen supply until the drug level is reduced and restoration of spontaneous circulation can be achieved.
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5/39. Ambulance transport of obstetric emergencies.

    Ninety-eight patient records from obstetric flying squad calls were reviewed. The reasons for call-out and the effect of transport on maternal and foetal cardiovascular parameters were analysed. The main reason for calling the flying squad is now antepartum haemorrhage. Transporting the patient to hospital has little effect on the cardiovascular state.
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6/39. Gamma hydroxybutyric acid (GHB): an increasing trend in drug abuse.

    The use of recreational drugs in society is becoming a widespread problem increasing the workload of all the emergency services. Gamma hydroxybutyric acid (GHB) is one of these, a drug used primarily for its euphoric effect. Toxic effects of ingestion include bradycardia, slow respiration or apnoea, coma and death. We present seven cases, all of which had consumed GHB either alone or in conjunction with other drugs and alcohol. The presentation, clinical features and management of these cases are described. All health care personnel involved in the emergency setting need to know of its existence, toxic effects and initial management with particular reference to airway control and possible assisted ventilation.
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7/39. negotiating the new health care system in Cape Town, south africa: five case studies of the acutely chronically ill.

    This article examines the experiences of chronically ill disadvantaged patients in a newly reformed health care system against a backdrop of inequalities still prevalent in the wider postapartheid sociopolitical economy of the Western Cape, south africa. patients negotiated a hierarchy of spaces at the national level of transformation and policy and at community-, secondary-, and tertiary-level facilities. The institutionalization of patients meant that expensive medical treatment was mobilized in accordance with different stages of illness and that certain services were available only to "qualifying" categories of diagnoses.
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8/39. Home-birth emergencies in the US and mexico: the trouble with transport.

    Proponents of the global Safe Motherhood Initiative stress that primary keys to safe home birth include transport to the hospital in cases of need and effective care on arrival. In this article, which is based on interviews with American direct-entry midwives and Mexican traditional midwives, I examine what happens when transport occurs, how the outcomes of prior transports affect future decision-making, and how the lessons derived from the transport experiences of birthing women and midwives in the US and mexico could be translated into improvements in maternity care. My focus is on home birth in urban areas in mexico and the US. In both countries, biomedicine and home-birth midwifery exist in separate cultural domains and are based on distinctively different knowledge systems. When a midwife transports a client to the hospital, she brings specific prior knowledge that can be vital to the mother's successful treatment by the hospital system. But the culture of biomedicine in general tends not to understand or recognize as valid the knowledge of midwifery. The tensions and dysfunctions that often result are displayed in midwives' transport stories, which I identify as a narrative genre and analyze to show how reproduction can go unnecessarily awry when domains of knowledge conflict and existing power structures ensure that only one kind of knowledge counts. This article describes: (1) disarticulations that occur when there is no correspondence of information or action between the midwife and the hospital staff; and (2) fractured articulations of biomedical and midwifery knowledge systems that result from partial and incomplete correspondences. These two kinds of disjuncture are contrasted with the smooth articulation of systems that results when mutual accommodation characterizes the interactions between midwife and medical personnel. The conclusion links these American and Mexican transport stories to their international context, describing how they index crosscultural markers, and suggest solutions, for "the trouble with transport."
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9/39. Tension pneumocyst after transsphenoidal surgery for Rathke's cleft cyst: case report.

    OBJECTIVE AND IMPORTANCE: Tension pneumocephalus is a rare but well-described complication of transsphenoidal surgery. It is usually associated with postoperative cerebrospinal fluid fistulae causing lower intracranial pressure, with air located in the subdural, subarachnoid, or intraventricular space. We report a case of suprasellar tension pneumocyst that caused visual deterioration to develop after an operation for a Rathke's cleft cyst. Only one similar case has been reported previously. CLINICAL PRESENTATION: A 54-year-old woman with a cystic sellar-suprasellar mass compressing the chiasm was operated on via a standard transsphenoidal approach. The intraoperative diagnosis was Rathke's cleft cyst, and the floor of sella was left open to avoid recurrence. The sphenoid sinus was filled with a fat graft, and the rostrum of the sphenoid was reconstructed with a bone fragment. The patient's postoperative course was uneventful, and her vision improved. Ten days after discharge, the patient was readmitted to the emergency service with headache and visual impairment. Emergent computed tomography confirmed a suprasellar tension pneumocyst. INTERVENTION: The patient underwent immediate reoperation via an endonasal endoscopic approach. After the trapped air was evacuated, the sella was closed with fascia lata and muscle using fibrin glue. The patient's vision improved postoperatively. CONCLUSION: Suprasellar tension pneumocyst is an extremely rare complication of transsphenoidal surgery. To avoid this complication, the sellar floor should be repaired in a watertight fashion, and patients should be instructed to avoid blowing the nose, sneezing, straining, and coughing postoperatively.
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10/39. Emergency management of acute myocardial infarction by the general practitioner.

    In the Cape GP Emergency Coronary Care Project, 129 general practitioners (GPs) collaborated over a 14-month period. The objectives were to reach all patients with symptoms of acute myocardial infarction as promptly as possible, and to institute therapy according to a simple protocol, where the emphasis was on the prophylactic administration of antidysrhythmic drugs. The results showed that 38% of a total of 333 patients received treatment within 1 hour of the onset of their symptoms, and 75% within 4 hours. The mortality at the end of 1 month was 15% in 333 patients of all ages, and 10,7% for 272 under the age of 70 years. The over-all community death rate from coronary heart disease in the patients of the participating GPs was 28,3% in 445 patients of all ages, and 23,3% in 356 patients under 70 years of age. These death rates are well below those reported in other comparable series. There was a low incidence of arrhythmic death, and only 1 death among patients who had received appropriate antidysrhythmic therapy. No ill-effects of complications occurred after the routine prophylactic administration of antidysrhythmic drugs. It is concluded that in the prehospital phase of acute myocardial infarciton, the Cape GPs were able to administer a service which compared favourably with that of a mobile intensive coronary care unit, at almost no extra cost to the community, and with very little extra strain on their practices.
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