Bilateral subdural hematoma after inadvertent dural puncture during epidural analgesia.

BACKGROUND: Post-dural puncture headache (PDPH) is typically a benign complication of dural puncture that is clinically diagnosed. It commonly presents as a throbbing and positional headache that occurs 24-48 h after dural puncture. Subdural hematomas, if unrecognized, may occur as a rare and life-threatening complication of dural puncture. OBJECTIVES: We aim to describe the clinical features and sequelae of a rare complication that may result as a consequence of inadvertent dural puncture that, if unrecognized, has the potential to become a life-threatening complication from a common procedure. CASE REPORT: We report the case of a previously healthy 17-year-old primigravida female who initially presented 4 days postpartum with clinical features and imaging studies consistent with PDPH. The patient's symptoms were unremitting, and within 4 weeks, she developed bilateral subdural hematoma. With prompt recognition and diagnosis, she was treated with conservative medical management and subsequently improved on follow-up. CONCLUSION: Patients with unremitting PDPH should prompt the clinician to suspect the development of subdural hematoma as a potential life-threatening complication of an otherwise benign condition.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs.

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials.

The Canadian Cardiovascular Society published a comprehensive set of recommendations on the diagnosis and management of heart failure in January 2006. Based on feedback obtained through a national program of heart failure workshops and through active solicitation of stakeholders, several topics were identified because of their importance to the practicing clinician. Topics chosen for the present update include best practices for the diagnosis and management of right-sided heart failure, myocarditis and device therapy, and a review of recent important or landmark clinical trials. These recommendations were developed using the structured approach for the review and assessment of evidence adopted and previously described by the Society. The present update has been written from a clinical perspective to provide a user-friendly and practical approach. Specific clinical questions that are addressed include: What is right-sided heart failure and how should one approach the diagnostic work-up? What other clinical entities may masquerade as this nebulous condition and how can we tell them apart? When should we be concerned about the presence of myocarditis and how quickly should patients with this condition be referred to an experienced centre? Among the myriad of recently published landmark clinical trials, which ones will impact our standards of clinical care? The goals are to aid physicians and other health care providers to optimally treat heart failure patients, resulting in a measurable impact on patient health and clinical outcomes in Canada.

"Medically cleared": how well are patients with psychiatric presentations examined by emergency physicians?

Significant numbers of patients present to Emergency Departments (ED) with psychiatric complaints, and alternative or concomitant medical diagnoses are commonly present. The literature reveals that physical examinations on these patients in the ED are often incomplete. The purpose of this study was to assess the completeness of examinations for "medical clearance" in our ED. We conducted a retrospective chart review of consecutive adult patients presenting to our ED over 1 year, using patients with a disposition diagnosis of "schizophrenia" as our subject group. The ED physician and nursing records were analyzed for 17 quantitative and qualitative variables, and these were stratified for age. Complete physical examinations were regularly lacking. Complete vital signs (VS) were documented in only 52% of cases, whereas no VS were recorded in 6% of patients. Older patients were more likely to receive full examinations, but this was not universal. Patients with psychiatric presentations should undergo a complete physical examination, including a full set of VS, before disposition from the ED.

An approach to complex acid-base problems: keeping it simple.

OBJECTIVE: To review rules and formulas for solving even the most complex acid-base problems. SOURCES OF INFORMATION: MEDLINE was searched from January 1966 to December 2003. The search was limited to English-language review articles involving human subjects. Nine relevant review papers were found and provide th background. As this information is well established and widely accepted, it is not judged for strength of evidence, a is standard practice. MAIN MESSAGE: An understanding of the body's responses to acidemia or alkalemia can be gained through a set of four rules and two formulas that can be used to interpret almost any acid-base problems. Physicians should, however, remember the "golden rule" of acid-base interpretation: always look at a patient's clinical condition. CONCLUSION: Physicians practising in acute care settings commonly encounter acid-base disturbances. While some o these are relatively simple and easy to interpret, some are more complex. Even complex cases can be resolved usin the four rules and two formulas.

Symptomatic bradycardia secondary to interaction between topical timolol maleate, verapamil, and flecainide: a case report.

We present a case report describing an interaction between topical timolol maleate, verapamil, and flecainide resulting in symptomatic bradycardia. Adverse drug interactions, including topical medications, are relevant in the differential diagnosis of many presenting complaints.

Painless acute aortic dissection and rupture presenting as syncope.

Acute aortic dissection is an emergency that may not only cause significant morbidity but often results in death. A timely diagnosis can prove difficult in the event of an atypical presentation. Classically, aortic dissection presents as sudden, severe chest, back, or abdominal pain that is characterized as ripping or tearing in nature. This article reports on a case of a completely painless acute dissection and rupture in a middle-aged man who presented with syncope. The diagnosis was made by a combination of clinical suspicion, emergent bedside echocardiography, and computed tomography scan. This patient underwent immediate surgery, and ultimately had a successful outcome.