Atheromatous embolism: an unusual case of acute lower extremity ischemia.

A case is presented of lower extremity ischemia related to atheromatous embolization that presumably occurred as a result of passage of an angiographic catheter through the aorta. The patient presented with signs and symptoms pathognomonic for this entity. Emergency physicians need to be aware of this unusual etiology for an ischemic lower extremity.

A comparison of prehospital estimated time of arrival and actual time of arrival to an emergency department.

The accuracy of the paramedic's estimated time until arrival (ETA) to an emergency department has never been studied. Two hundred and eighty paramedic runs were prospectively studied in a suburban, residency-affiliated emergency department. The average ETA was 7.39 +/- 3.72 minutes. The average actual time until arrival, as clocked by the directing emergency physician was 10.29 +/- 3.95 minutes. Two hundred and twenty-seven (81%) patients arrived later than their ETA. There were 24 (8.5%) cases where the physician's prehospital management would have been different had the ETA been more accurate.

Posttachycardia T-wave changes.

A 25-year-old previously healthy man presented to the emergency department with a tachydysrhythmia. After pharmacological intervention, the patient's rhythm converted to normal sinus and symmetrically inverted T-wave changes were noted. Although asymptomatic after conversion, the patient was admitted to the hospital and monitored for two days to rule out cardiac ischemia correlating with the T-wave changes. The patient was ultimately discharged in good health. A review of the emergency medical literature fails to reveal examples of post-tachycardic T-wave changes that may simulate myocardial ischemia but be of no clinical significance.

Forearm and wrist radiology: Part II.

The emergency physician must be well versed in diagnosing forearm and wrist injuries. Although many of these injuries are readily apparent, others require more sophistication to appreciate. Careful attention to radiographic findings given the assistance of a well-directed history and physical examination is imperative. Both the more common and the more subtle injuries will be discussed.

Forearm and wrist radiology--Part I.

The emergency physician must be well versed in diagnosing forearm and wrist injuries. Although many of these injuries are readily apparent, others require more sophistication to appreciate. Careful attention to radiographic findings given the assistance of a well-directed history and physical examination is imperative. Both the more common and the more subtle injuries are discussed.

Reliability of a urine dipstick in emergency department patients.

We conducted a study to examine whether a negative Chemstrip 9 result for leukocyte esterase and nitrite would reliably exclude an abnormal microscopic examination of the urine of emergency department patients. Three hundred urine specimens were subjected to Chemstrip 9 evaluations and full microscopic examinations in the microscopy laboratory. As the microscopy laboratory examination identified lower WBC and bacteria counts, increasing numbers of false-negative urine dipsticks results occurred. The results of our study reveal that the nitrite and leukocyte esterase assays miss significant microscopic findings with corresponding clinical pathology, with the nitrite examination being the less sensitive of the two tests. Based on our results, we believe it would not be prudent to use the Chemstrip 9 dipstick in the ED to exclude the presence of WBC and bacteria in the urine.

Pulmonary edema in the renal failure patient.

A patient with chronic renal failure presenting to the emergency department with acute pulmonary edema has a true life-threatening emergency. Whereas conventional treatment modalities may prove useful, more unusual therapeutic measures may be necessary. A case is presented followed by useful recommendations for the emergency physician faced with such a patient.

Blood component therapy.

The emergency physician must have a solid understanding of the use of blood products. This article discusses how to order various blood products, problems with storage, when to administer them, what special equipment is necessary, and possible complications of their use. Special attention is paid to the many different components that are available for specific indications.

Catheter embolism.

With the increasing utilization of intravenous catheters, complications from their use may be anticipated. We report the case of one such complication, a venous catheter fragment embolization. A review of the literature addressing catheter embolization is provided. Specific recommendations are offered to the emergency physician in an effort to minimize such untoward occurrences.

Pelvic fractures and related clinical injuries.

Pelvic fractures represent major injuries by themselves, and are especially serious when associated with commonly occurring related clinical injuries. Initial evaluation of the trauma victim must include consideration of this injury and its related complications. Evaluation of the fracture and its related injuries must be well-directed and aimed at minimizing potential morbidity and mortality. A multi-disciplinary approach that includes consultation with the trauma surgeon, urologist, and orthopedic surgeon must be used.

Calcium and its role in cardiac arrest: understanding the controversy.

Calcium ions play a critical role in excitation-contraction coupling in the myocardial cell, leading to enhanced automaticity and contractility. For these reasons the American Heart Association and the National Academy of Science-National Research Council has advocated its use in cardiac arrest due to asystole and electromechanical dissociation (EMD). However, increasing evidence suggests that calcium has been of little benefit in cardiac arrest not only because of the poor salvage rates (0%-8%) of victims in asystole or EMD and the dangerously high serum calcium levels following standard calcium administration, but also because of the cellular accumulation of calcium within the myocardium that occurs during cardiac arrest. In fact, some authors advocate the use of calcium channel blockers in protecting myocardial tissue during anoxia. Therefore the usefulness of calcium in asystole and EMD is highly suspect and must be reevaluated.