Environmental injuries.

Environmental injuries and illnesses can happen in home, work, or recreational settings. The variety and severity of these injuries might require the clinician to call on skills from internal medicine, emergency medicine, and toxicology. Diseases of thermoregulation are hypothermia and hyperthermia. In each instance, treatment is based on the need to restore the patient's core temperature to normal and on monitoring for complications. The victim of a fire might suffer inhalation injury in addition to burns, and it is more likely that the inhalation injury will be fatal. Oxygen deprivation and inhalation of irritant or asphyxiant chemicals contribute to injury. Toxic plants can be the source of poisoning emergencies, especially in children. Misinformation and myths that surround common plants can create diagnostic problems (i.e., which plants really are toxic and require emergency measures). Venomous marine organisms can cause a wide range of injury, from cutaneous eruption to fatal envenomation. Most are encountered in a recreational setting, such as water sports, but keepers of home aquariums are subject to stings from venomous fish. Lightning injury can present many diagnostic and treatment dilemmas. An important point in this regard is that lightning injury and high-voltage electrical injury are different in pathology and require different approaches for treatment. A discussion of electrical, chemical, and thermal burns makes such differences apparent.

Ciguatera poisoning after ingestion of imported jellyfish: diagnostic application of serum immunoassay.

Ciguatera fish poisoning is an important public health problem wherever humans consume tropical and subtropical fish. It accounts for over half of fish-related poisonings in the United States but is uncommonly diagnosed and underreported. Produced by dinoflagellates, ciguatoxin accumulates up the food chain in herbivorous and carnivorous fishes. Cnidaria jellyfish and related invertebrates) have not previously been associated with direct ciguatera intoxication in humans. We report the first case of ciguatera fish poisoning associated with cnidarian ingestion. A 12-year-old Tongan female presented to our Emergency Department with mid-abdominal pain, nausea, change in mental status, and new-onset movement disorder after ingestion of jellyfish imported from American Samoa. Clinical diagnosis was confirmed by strongly positive serum identification of ciguatoxin and related polyether toxins (including okadaic acid) with a rapid extraction method (REM) and highly reliable solid-phase immunobead assay (S-PIA) performed by the Food Toxicology Research Group, University of Arizona. Ciguatera pathophysiology, clinical presentation, differential diagnosis (including consideration of palytoxin poisoning), and treatment are briefly reviewed. We emphasize the growing incidence of ciguatera fish poisoning outside "high-risk" areas. In regions with immigrant populations, privately imported exotic fish may be toxin vectors. Marine species other than carnivorous fish are now suspect in human ciguatera intoxication. Reliable tests can aid in premarket fish testing, diagnosis, and follow-up of ciguatera fish poisoning. The global prevalence of marine toxins demands fishermen, consumers, and physicians maintain a high index of suspicion for ciguatera fish poisoning.

Evaluation of a portable clinical blood analyzer in the emergency department.

OBJECTIVE: To assess the potential effects of rapid bedside blood analysis on patient management in the ED. METHODS: A prospective, nonrandomized clinical study was conducted over a consecutive ten-month period (August 1992 to May 1993). Blood samples drawn from a convenience sample of 960 patients for analysis of Na+, K+, Cl-, BUN, glucose, and/or hematocrit (Hct) were simultaneously analyzed by portable clinical analyzer (PCA) and by routine methods in the central laboratory. Caregivers were blinded to the PCA values; patient care was based solely on central laboratory results. Physicians were surveyed after the completion of patient care. RESULTS: The PCA results were available 31 minutes (mean) sooner than were the central laboratory results for Hct, 43 minutes faster for Na+, K+, and Cl-, and 44 minutes faster for BUN and glucose. Except for Hct and glucose, the values obtained from the PCA were not significantly different from the central clinical blood analyzer laboratory values. When surveyed, the physicians caring for the patients reported that had the PCA results been available, a different or an earlier therapeutic approach would have resulted in 9.5% of the cases. The decision to release or admit the patient was based on one or more of the laboratory values for 10.7% of patients sampled. In no case in this series did a physician report that final ED clinical outcome would have been affected. CONCLUSIONS: In our ED, the PCA yielded faster reporting of laboratory values. These earlier results might have reduced the length of stay in the ED for 17.3% of patients studied. Selective use of a handheld portable analyzer might decrease time to therapeutic interventions and time to disposition.

Environment-dependent sports emergencies.

As more individuals participate in sports and outdoor activities, the frequency of environmentally related illnesses will increase. Participants in sporting events of long duration and those requiring particularly inclement weather and adverse conditions are especially prone to developing injury. Hypothermia, heat-related illnesses, and high-altitude illnesses are multisystem emergencies that require immediate, specific therapeutic maneuvers. Physicians must be able to recognize the signs and symptoms of these medical emergencies and institute definitive care. Rapid core rewarming, airway control, and prolonged cardiopulmonary resuscitation are the key factors in managing the hypothermic patient. Adequate cooling and volume resuscitation provide the basis for treating the hyperthermic patient. The patient with high altitude-related illness should be returned to a lower elevation and given supplemental oxygen. Specific intervention depends on the patient's presentation. Environmental illnesses cause severe morbidity and mortality and are frequently within the control of the sport participant. Thus physicians must educate their patients on basic preventive measures if they are going to participate in outdoor sporting activities.

Wilderness injuries and illnesses.

STUDY OBJECTIVE: To determine injury and illness patterns and occurrence rates during wilderness recreation. DESIGN: Prospective injury and illness surveillance study. SETTING: Wilderness areas throughout the Western hemisphere. TYPE OF PARTICIPANTS: All students and instructors on National Outdoor Leadership School courses over a five-year period. MAIN RESULTS: A single fatality occurred, resulting in a death rate of 0.28 per 100,000 person-days of exposure. Injuries occurred at a rate of 2.3 per 1,000 person-days of exposure. Sprains and strains and soft tissue injuries accounted for 80% of the injuries. The illness rate was 1.5 per 1,000 person-days of exposure. Sixty percent of illnesses were due to nonspecific viral illnesses or diarrhea; hygiene appeared to have a significant impact on the incidence of these illnesses. Thirty-nine percent of the injuries and illnesses required evacuation (1.5 per 1,000 person-days of exposure). CONCLUSION: The injury and illness patterns indicate that wilderness medical efforts should concentrate on wilderness hygiene and management of musculoskeletal injuries and soft tissue wounds. The data also indicate that wilderness activities can be conducted relatively safely, but the decision to participate should be individualized, with an understanding of risks versus benefits.

The leukocyte esterase test for detection of cerebrospinal fluid leukocytosis and bacterial meningitis.

We conducted a study to assess the efficacy of the dipstick leukocyte esterase test (LET) in the detection of cerebrospinal fluid (CSF) leukocytosis as a quick screen for bacterial meningitis. Nine hundred forty-two CSF samples were collected from 800 patients. The LET was compared in a double-blinded fashion with routine cell count determinations and cultures. We reviewed the clinical courses of all patients with positive cultures to assess the significance of culture isolates. Statistical analysis revealed LET sensitivity of 84.4% and specificity of 98.1% for clinical presentations of bacterial meningitis for which initiation of therapy is currently recommended. The LET identified culture-proven cases of meningitis with sensitivity of 73% and specificity of 95%. We propose the LET as an adjunct to, but not a replacement for, CSF cell count and chemistry determination in the initial laboratory assessment of bacterial meningitis. It is a reasonable screen that allows rapid initiation of treatment and directs the laboratory technician to devote extra attention to examination of a CSF specimen with a higher likelihood of pathology.

Radiographic assessment of renal trauma: a 10-year prospective study of patient selection.

To develop criteria to determine which patients require radiographic assessment after blunt renal trauma, we studied prospectively 1,146 consecutive patients with either blunt (1,007) or penetrating (139) renal trauma between 1977 and 1987. Based on our preliminary results from 1977 to 1983, in which none of the 221 patients with blunt trauma and microscopic hematuria without shock had significant renal injuries, we designed a prospective study to determine if such patients could be managed safely without radiographic staging. During the last 10 years significant renal injuries were found in 44 patients (4.4 per cent) with blunt trauma and gross hematuria or microscopic hematuria associated with shock, and in 88 patients (63 per cent) with penetrating trauma. No significant injuries occurred in the 812 patients with blunt trauma and microscopic hematuria without shock, 404 of whom had complete radiographic assessment and 408 of whom did not. There were no delayed operations or significant sequelae related to the renal injury in these patients. We conclude that complete radiographic staging is mandatory in patients with penetrating trauma to the flank or abdomen and in patients with blunt trauma associated with either gross hematuria or microscopic hematuria and shock. However, patients with blunt trauma, microscopic hematuria and no shock who do not have associated major intra-abdominal injuries can be managed safely without excretory urography.

Hypokalemic periodic paralysis: two case reports.

We report two cases of hypokalemic periodic paralysis in children presenting to the emergency department with diffuse weakness and no antecedent history of neurologic disease. The literature is briefly reviewed. Any child with acute weakness and normal mental status should undergo serum potassium determination to allow prompt diagnosis and therapy.

Erythema nodosum following a jellyfish sting.

At least 100 of the approximately 9,000 species of coelenterates are dangerous to humans. The most common syndrome following an envenomation is an immediate intense dermatitis, with characteristic skin discoloration, local pain, and systemic symptoms. In this case report, we describe a case of erythema nodosum with articular manifestations following envenomation with an unknown jellyfish. Serological testing of the victim revealed marked elevation of immunoglobulins G and M directed against Physalia physalis, the Portuguese man-of-war. The patient's condition did not respond to conventional topical therapy for coelenterate envenomation, but was successfully managed with systemic corticosteroid therapy. This case demonstrates that the emergency physician should consider a delayed reaction to a marine envenomation in any victim who presents with an acute dermatological disease following immersion in marine coastal waters.

Acinetobacter calcoaceticus infection following a dog bite.

A frequent complication of dog bite wounds is bacterial infection. The choice of antibiotics is based upon the most likely organisms. Failure to achieve wound healing suggests that an uncommon organism(s) is present and should lead the clinician to culture the wound. A case of Acinetobacter calcoaceticus infection following a dog bite is described.