Thrombotic thrombocytopenic purpura presenting as bilateral flank pain and hematuria: a case report.

Thrombotic thrombocytopenic purpura (TTP) is a rare disease whose incidence is now increasing. We present a case of a 37-year-old man who presented with bilateral flank pain and hematuria, subsequently diagnosed with TTP. Thrombotic thrombocytopenic purpura has classically been characterized by the pentad of fever, microangiopathic hemolytic anemia, neurologic symptoms, renal dysfunction, and thrombocytopenia. The pathogenesis of the disease has been a mystery until recently. We review the current literature regarding the pathophysiology and management of this disorder. Our discussion focuses on the importance of understanding this disease while considering the differential diagnosis of a patient presenting with anemia and thrombocytopenia because the common pitfall of rapidly administering platelets to a patient with TTP may lead to a disastrous outcome.

Functional decline in independent elders after minor traumatic injury.

OBJECTIVES: To describe injury types, patterns, and health status in independently functioning elder patients presenting to the emergency department (ED) after a minor traumatic injury; and 2) to assess short-term functional decline in this population at three-month follow-up. METHODS: This was a prospective observational study of elder patients (age > 65 years) discharged home from the ED after evaluation and treatment for an acute traumatic injury. Patients were excluded if they were not independently functioning or had an acute delirium. Type and mechanism of injury sustained during the ED visit were recorded. Functional status was assessed during the visit and three months later using activities of daily living (ADL) and instrumental activities of daily living (IADL) scores. RESULTS: One hundred six subjects were enrolled in the study. Mean age was 74.8 years. The most common injuries observed were contusion (n = 35, 33%, 95% CI = 24% to 42%), fractures (n = 28, 26%, 95% CI = 18% to 36%), lacerations (n = 20, 19%, 95% CI = 12% to 28%), and sprains (n = 12, 11%, 95% CI = 6% to 19%), which represented more than 90% of the injuries. Eighty-eight (83%) patients completed three-month follow up. Of these, 6 of 88 (6.82%, 95% CI = 3% to 14%) declined in their ADL scores and 20 of 88 (22.73%, 95% CI = 14% to 33%) declined in their IADL scores at three months. Primary injury type, specifically contusion, was more prevalent in patients who had a decline in ADL score, as compared with those who did not have a decline in ADL score (chi-square p<0.001). In addition, anatomic locations of injury were different between those patients with and without a decline in IADL scores (chi-square p = 0.008). Gender differences were also found; females were more likely to be injured by a slip, trip, or fall indoors (36 of 58, 62%) than outdoors (22 of 58, 38%); males injured by this mechanism were more likely to be injured outdoors (14 of 20, 70%) as opposed to indoors (6 of 20, 30%), chi-square p = 0.013. CONCLUSIONS: A significant proportion of functional elder patients with minor traumatic injury are at risk for short-term functional decline. Decline in ADL is related to injury type, while IADL decline is related to anatomic location of injury. Emergency physicians should consider initiating follow-up evaluation and possible intervention in highly functioning elders after minor traumatic injury.

Field experience with prehospital advance directives.

STUDY OBJECTIVE: Some states have enacted legislation authorizing EMS providers to adhere to prehospital advance directives (ADs) in the terminally ill. This study was conducted to assess EMS providers' knowledge of and experience with prehospital ADs. METHODS: An anonymous survey was conducted of 142 EMS providers employed by a local, private ambulance service in the northeastern United States. The survey was administered during a 2-month period from January to March 1995. RESULTS: Of 142 participating providers, 106 (74.6%) completed questionnaires. Respondents included EMTs (61. 3%), paramedics (33.9%), and chair van operators (4.8%). The majority (58.6%) had at least 5 years of field experience. Almost all respondents (93.4%) were familiar with ADs, usually do-not-resuscitate orders. Most providers (78.3%) consider ADs before implementing extraordinary life support measures in terminally ill patients. Few (28.0%) have implemented prehospital ADs without medical control. The most commonly reported objections to withholding life support measures were fear of legal consequences, personal difficulty withholding care they are trained to provide, and ambiguity in the ADs received. Nearly all respondents (96.7%) support enactment of prehospital AD statutes. CONCLUSION: Most prehospital care providers recognize the need to withhold resuscitative care in terminally ill patients who have prepared ADs. However, a sizable minority fail to consider prehospital ADs as a routine part of their practice. The majority of our respondents support enactment of prehospital AD statutes to minimize confusion and provide legal authorization to limit resuscitation.

Emergency medicine in west Kazakhstan, CIS.

Now a member of the Commonwealth of Independent States, Kazakhstan is the second largest of the republics that made up the former Soviet Union. This report describes the structure of the health care system in Kazakhstan, with particular emphasis on emergency medicine. It examines medical education, the organization of health care services, emergency medical services, emergency department structure, and the challenges facing emergency medicine.

Causes and patterns of injury from ladder falls.

OBJECTIVES: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre-event and event factors could have reduced the likelihood of a fall or a resulting injury. METHODS: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall. RESULTS: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged > 18 years (mean 42.9 +/- 16.2 years), were predominantly male (93%), and had fallen a distance of 1-15 feet (mean 7.2 +/- 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related. CONCLUSIONS: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.

Sports-related pneumothorax.

Pneumothorax and pneumomediastinum are rare complications of athletic activity. Spontaneous pneumothorax has been reported in association with several sports, but reports of pneumothorax associated with blunt trauma sustained during sporting activity are rare. We present a case series of patients in whom pneumothorax or pneumomediastinum developed as a result of blunt trauma sustained during participation in a contact sport.

Air bag safety.

STUDY OBJECTIVE: To describe injuries associated with deployment of air bag passive-restraint systems in use in the United States. DESIGN: Retrospective review of data collected by the National Highway Traffic Safety Administration (NHTSA) from 1980 to 1994. PARTICIPANTS: Occupants of air bag-equipped vehicles who were involved in crashes on US roads. RESULTS: Of 618 reported occupant injuries related to air bag deployment, an overwhelming majority were classified as minor (96.1%). Most occupants sustained abrasions, contusions, and lacerations. The face (42.0%), wrist (16.8%), forearm (16.3%) and chest (9.6%) were the most frequently injured body areas. CONCLUSION: Most injuries related to air bag deployment are minor and must be viewed in the context of the potentially life-threatening injuries they prevent.

Use of thrombolytic therapy in a heart transplant recipient with acute myocardial infarction.

We report the case of a 54-year-old long-term heart transplantation survivor who presented to the emergency department with acute myocardial infarction and was treated successfully with thrombolytic therapy. The case is discussed, and pertinent literature is reviewed.