Pneumocephalus following an epidural blood patch procedure: an unusual cause of severe headache.

Pneumocephalus is a rare complication of anesthetic procedures involving the epidural space. We report the case of a 36-year-old woman who developed a severe headache due to pneumocephalus that occurred during an epidural blood patching procedure. This report reviews the blood patch procedure and its attendant complications. Emergency physicians should be aware of the potential complications of this commonly performed procedure and include iatrogenic pneumocephalus in the differential diagnosis of severe headache in the proper clinical scenario.

Flumazenil: an antidote for benzodiazepine toxicity.

Flumazenil, a specific benzodiazepine antagonist, is useful in reversing the sedation and respiratory depression that often occur when benzodiazepines are administered to patients undergoing anesthesia or when patients have taken an intentional benzodiazepine overdose. Judicious use of flumazenil may provide useful diagnostic information and may obviate the need for mechanical ventilation and other invasive supportive measures. Although some controversy exists regarding the possible precipitation of seizure activity in the setting of mixed tricyclic antidepressant-benzodiazepine overdose, worldwide experience with flumazenil has validated its safety and efficacy.

Digitalis toxicity. Using immunotherapy when supportive care isn't enough.

Significant digitalis toxicity, although uncommon, is a medical emergency. Recognition of the problem and good supportive care (eg, administration of activated charcoal and binding resins, correction of potassium levels, restoration of heart rhythm) are the cornerstones of treatment. If indicated, immunotherapy with digoxin immune Fab (Digibind) is a valuable and effective tool.

An analysis of invasive airway management in a suburban emergency medical services system.

INTRODUCTION: Airway management is the most critical and potentially life-saving intervention performed by emergency medical service (EMS) providers. Invasive airway management often is required in non-cardiac-arrest patients who are combative or otherwise uncooperative. The success of prehospital invasive airway management in this patient population was evaluated. METHODS: A retrospective review was undertaken of the records of all such patients requiring endotracheal intubation over a three-year period (1987-1989). The study population included 278 patients enrolled by five advanced life support (ALS) units serving a suburban population of 425,000. Field trip sheets were reviewed for diagnosis, intubation method and success, number of intubation attempts, provider experience, reasons for unsuccessful intubations, and complications. RESULTS: A total of 394 invasive airway management attempts were performed on 278 patients. The overall successful intubation rate was 75% (41% orotracheal, 52% nasotracheal, 7% other or unknown). The most common diagnoses were COPD and pulmonary edema (30%) and trauma (24%). Experienced providers were successful on the first attempt in 57% of cases compared to 50% by inexperienced providers (p=.24). Multiple intubation attempts were required in 33% of the patients. There was no statistically significant difference in success rates between the orotracheal and nasotracheal methods (p=.51). The most common reason for unsuccessful intubation was altered level of consciousness. Complications occurred with 7% of successful attempts and in 18% of unsuccessful attempts (p less than .001). Forty-six percent of the patients who were not intubated successfully in the field and required intubation in the emergency department (ED) received a neuromuscular blocking agent prior to successful intubation. CONCLUSION: Prehospital providers can intubate a high but improvable proportion of non-cardiac-arrested patients by both the orotracheal and nasotracheal routes. The use of pharmacologic adjuncts to facilitate the prehospital intubation of selected, non-cardiac-arrested patients is a promising adjunct that needs further evaluation.

Atrial fibrillation with cardiac tamponade as the initial manifestation of malignant pericarditis.

This article describes the case of a 72-year-old woman with cardiac tamponade and atrial fibrillation as the initial manifestation of a lymphoid malignancy. The pathogenesis of cardiac tamponade, various diagnostic modalities, and therapy of this condition are reviewed.