Urolithiasis in a child: an uncommon presentation of an uncommon disease.

Urolithiasis in children is uncommon. We present the case of a 10-year-old boy with anuria resulting from an obstructing stone in the urethral meatus. There are no previously reported cases of pediatric urolithiasis presenting with anuria. We review urolithiasis in children, including predisposing factors, clinical features, stone composition, and natural history. The diagnosis may be confusing in younger children but should be considered with complaints of flank or abdominal pain, hematuria, and urinary tract infection.

Bacterial meningitis in infants and children: a review.

Emergency physicians are often required to evaluate febrile infants and children with no obvious source of infection. Most have uncomplicated viral illnesses. It is imperative, however, to identify the child with potentially life-threatening bacterial meningitis. The clinical presentation of meningitis is variable and depends on many factors. These variables are discussed as well as the indications for lumbar puncture and guidelines for laboratory evaluation. Recommendations for antibiotic selection and dosages are provided. The clinical trials regarding the use of dexamethasone are also reviewed.

Paraesophageal hernia in an elderly woman.

We present a case of an elderly woman with a paraesophageal hernia. This is an uncommon type of hiatal hernia and may result in a surgical emergency if incarceration, obstruction, or strangulation is present. Our patient presented with a clinical picture consistent with myocardial ischemia. We discuss the differential diagnosis, the pathophysiology, complications, diagnostic studies, and treatment of this disease.

Objective determination of the optimal red blood cell count in diagnostic peritoneal lavage done for abdominal stab wounds.

The purpose of this study was to determine objectively the optimal value or positivity criterion for red blood cell counts in diagnostic peritoneal lavage in stab wounds to the anterior abdomen. Our study group consisted of 91 consecutive adults with abdominal stab wounds who underwent peritoneal lavage. We excluded those patients who met criteria for immediate laparotomy and those with negative stab wound exploration. We divided the patients into two groups based on outcome. Group 1 consisted of those who had undergone laparotomy and had findings that required surgical intervention. Group 2 patients had either undergone laparotomy but had no injury requiring surgical intervention or had no surgery and a benign hospital course and follow-up. Receiver operator characteristic analysis was done on the diagnostic peritoneal lavage RBC counts for both groups. The overlap between the groups was minimal, with 75% of patients in Group 1 having > 120,000 RBC/mm3 and 75% of patients in Group 2 having < 486 RBC/mm3 in the lavage effluent. Using the observed probability of 23.1% of patients with abdominal stab wounds requiring surgery, a RBC count of 50,000/mm3 discriminated best those patients who required surgery from those who did not.

Sickle-cell anemia--a review.

Sickle-cell anemia is a common disease, affecting more than 50,000 blacks in the United States. Since 1970 the morbidity and mortality have improved, with patients surviving well into their fourth decade. This article discusses the spectrum of serious complications of sickle-cell anemia. Crises and complications that result from the sickling process are presented with recommendations for emergency department evaluation and management. The painful bone crisis and pain control are also discussed.

Management of gynecologic oncology emergencies.

Gynecologic malignancies are the third most common cancer among women in the United States. Because of often subtle early findings, the diagnosis may not be made before the widespread dissemination of the disease. The Emergency Department physician will commonly encounter a woman with vaginal bleeding, pelvic pain, or a symptomatic abdominal mass. In this article, we have described the epidemiology, recognized patterns of spread, and associated findings of gynecologic tumors. The proper Emergency Department evaluation and management of these problems is emphasized with guidelines for the timing of referrals and consultation with the gynecologic oncologist. The treatment of gynecologic malignancies is often complicated and responsible for Emergency Department visits. The various modalities are addressed according to the organ systems affected and include sections on postoperative problems, gastrointestinal complaints, urologic complications of therapy, radiation therapy and its complications, with an emphasis on the most serious complications necessitating either careful outpatient management or hospital admission. As cost-containment pressure grows, we have included sections on chemotherapy and total parenteral nutrition, both of which are becoming common outpatient events for the cancer patient.

Septic shock (Part 1).

Septic shock is a distinct clinical entity with an overall mortality of 30% to 40%. Gram-negative organisms are the most frequently identified causal agents. The shock syndrome appears to result from activation of complement, coagulation, kinin, endorphin, and other hormonal systems. Physiologic abnormalities include hypotension, metabolic acidosis, increased cardiac index, and decreased tissue extraction of oxygen. Clinicians must entertain the diagnosis of septic shock in a variety of settings, as prognosis is affected by early institution of therapy. Treatment is directed toward control of infection with antibiotics and surgical drainage and cardiorespiratory support utilizing fluids and pressor agents. Future therapeutic options may include naloxone, cyclooxygenase inhibitors, and antiserum to endotoxin.