Vaginal discharge in the adult: a practice guideline.

A practice guideline as a preformatted chart is presented. It is designed to be simple in concept and design, easy to use, parsimonious of data, easily scanned for quality assurance, and to provide clinical and cost-effectiveness prompts. It has supporting medical information for all recommendations that is literature- and experience-based. A patient aftercare instruction sheet is appended. An abbreviated "pocket practice guideline" is also provided. This format is clearly appropriate only for simple, not complex, clinical encounters.

Appropriate management of chemical dependency in emergency medicine residents.

When chemical dependency is suspected in an emergency medicine resident physician, prompt and appropriate action must be taken to ensure the best possible outcome for all involved. Although residency program accreditation requires that program directors be able to appropriately deal with a chemically dependent resident, few programs have a formal policy in place, and little if any information exists for the formulation of such a policy. Presented here is a discussion of the disease of chemical dependency and how it affects emergency medicine residents, along with practical recommendations for appropriate management.

Late vascular perforations by CVP catheter tips.

Late perforations of vascular structures by central venous pressure (CVP) catheter tips are unusual, but potentially lethal, complications. The two principal syndromes caused by such perforations are described, and methods of prevention and treatment are outlined.

External jugular vein cannulation and its use for CVP monitoring.

The techniques of external jugular vein (EJV) cannulation and central venous pressure (CVP) catheter placement using a J-tipped wire guide is described in detail. This technique has a high success rate with virtually no complications.

Fatality secondary to misuse of TAC solution.

The death of a 7 1/2-month-old girl from the misuse of tetracaine/adrenalin/cocaine solution for wound anesthesia is reported. Ten milliliters of the solution inappropriately came into contact with nasal mucous membranes, causing excessive drug absorption. The patient's death probably was due to cocaine toxicity (post-mortem blood level, 11.9 mg/L).

Intravenous phenobarbital for alcohol withdrawal and convulsions.

In a prospective, uncontrolled study, 62 alcoholic patients received IV phenobarbital (IV-PB) to treat the alcohol withdrawal (AW) syndrome. Initially 260 mg of IV-PB were administered followed by 130 mg every 30 minutes to an end point of light sedation. A mean loading dose of 598 (+/- 192) mg of IV-PB resulted in a mean increase in the serum PB level of 13.9 (+/- 4.7) microgram/mL. Thus, the serum PB level rose 1.65 micrograms/mL for each mg/kg of IV-PB administered to these adult patients in AW. Forty-six of 48 tremulous patients (96%) showed improvement in their AW tremors. None of the 38 patients who presented with AW seizures had another convulsion during a mean observation period of three hours and 47 minutes. Transient ataxia or over-sedation occurred in three of 62 patients (5%) and was exacerbated by concurrent ethanol, diazepam, or phenytoin (six of 17), who were excluded from the study. We conclude that IV-PB is a safe and efficacious therapy for mild to moderate AWS, and IV-PB may prevent AW seizures.

Femoral vein cannulation: a review.

The femoral vein is an excellent potential venous access site. The technique of cannulation is described and its applications and complications are reviewed. More extensive future use of this technique is necessary to determine its proper role in emergency medicine.

"Code Red" protocol for resuscitation of the exsanguinated patient.

A "Code Red" protocol for resuscitation of the exsanguinated patient is presented. It consists of two phases initial massive crystalloid infusion, followed by rapid access to, and infusion of, blood. It is simple and requires minimal time, equipment, personnel, or expertise. The femoral vein is the principal access site; it is cannulated percutaneously by the Seldinger technique and allows simultaneous infusion and CVP measurement.

Standards for attending staff in an emergency medicine residency program.

An academic emergency department established comprehensive standards for its attending staff. Extensive input from multiple levels of emergency department (ED) personnel were utilized. There was uniform agreement that written roles and responsibilities were needed for a more efficiently operating department. Written standards for attending staff represent a novel approach in ED administration.

Acute upper airway obstruction.

Methods for controlling the airway in a variety of clinical situations are comprehensively reviewed. Use of mechanical ventilatory support should be considered when spontaneous respiration is inadequate, but the modality chosen must be adapted to the individual patient.

Use of wire-guided (Seldinger-type) catheters in the emergency department.

The use of wire-guided catheters is a major technical advance for emergency physicians. The technique is simple, safe, and efficient, and allows tremendous flexibility in usage.

Ketamine dissociative anesthesia--emergency department use in children.

An on-going study to determine the efficacy and safety of ketamine dissociative anesthesia in the emergency department for children less than 10 years of age is presented. Preliminary results of the first 30 cases indicate that this technique may be safe and convenient if used within the appropriate protocol.

Central venous cannulation and pressure monitoring.

Central venous pressure (CVP) varies directly with circulating blood volume and vascular tone and inversely with right heart competency. Indications for central cannulation include cardiorespiratory arrest. The two general approaches to cannulation of central veins are peripheral and central. The physician's skill, patient's body habitus, clinical circumstances, age and thoracic deformity all influence the choice of technique. Three of the possible complications discussed are pneumothorax, arterial puncture and air embolus. Accurate measurement of CVP depends on the patient being supine, a patent and accurately located catheter and the establishment of a baseline external zero point.

Pseudoasthma: a new clinical entity?

A functional syndrome resembling either asthma or airway obstruction, or both, is described. It is probably caused by voluntary glottic closure. Therapy with sedation and reassurance has proven successful. Patients with this syndrome must be carefully examined and observed to exclude the possibility of organic upper airway obstruction.