Autonomic dysreflexia presenting as a severe headache.

Hypertension, bradycardia, and severe headache have been associated with autonomic dysreflexia. Autonomic dysreflexia affects those with spinal transection above the level of T6 after plastic changes of the afferent pathways. This restructuring in the presence of noxious stimuli below the level of the lesion leads to autonomic dysreflexia. The onset of the first episode of autonomic dysreflexia has been documented as soon as 30 days and as late as 13 years after the injury. This report presents a case study of a paraplegic man 8 years after injury with autonomic dysreflexia associated with a urinary tract infection.

Effectiveness of selective use of intravenous pyelography in patients presenting to the emergency department with ureteral colic.

OBJECTIVE: To determine whether i.v. pyelography (IVP) is required routinely for all patients presenting to the ED with ureteral colic. METHODS: A randomized prospective study was conducted with 2 patient group-a routine IVP group, in which all patients underwent IVP, and a selective IVP group, in which patients were treated, observed, and released without undergoing IVP unless they experienced continued symptoms. The study was performed in a large university-affiliated, community hospital ED. Participants were patients aged 18-65 years with signs and symptoms consistent with ureteral colic. RESULTS: Among the 40 patients enrolled in the routine IVP group, 26 had positive studies, 8 of which necessitated hospitalization. Among the 41 patients randomized to the selective IVP group, there were only 19 IVPs performed, of which 6 were positive and 4 necessitated hospitalization. Compared with the routine IVP group, there were 54% fewer IVPs performed and a 51% lower admission rate in the selective IVP group. Despite the fact that fewer IVPs were performed in the selective IVP group, clinical outcomes in the 2 groups were similar, without significant complication in either group. CONCLUSIONS: IVPs do not need to be routinely performed for all patients presenting to the ED with ureteral colic. The decision to perform an IVP may be dictated by symptoms that persist after initial evaluation and treatment.

Telephone follow-up for case finding of domestic violence in an emergency department.

OBJECTIVE: To determine whether telephone follow-up of selected female patients seen in an urban ED would improve domestic violence (DV) case finding. METHODS: A prospective, cross-sectional study was conducted on consecutive female patients between the ages of 16 and 65 years treated in an urban trauma center during July and August 1995. Record review identified those patients with conditions suggesting increased risk for DV: injury; substance abuse; complaints or diagnoses related to stress, anxiety, depression, or panic attack; or complaints of headache, nonspecific abdominal pain, generalized fatigue, or numbness lasting > 1 week. Attempts were made to telephone all patients who had high-risk presentations within 3 days of their emergency visits. Patients were contacted by a trained interviewer regarding the circumstances of their visits. RESULTS: There were 142 (9%) high-risk presentations out of 1,500 ED visits by women. Of these high-risk visits, 68 patients denied DV, 19 patients did no speak English, 16 patients gave an incorrect telephone number, 18 patients could not be reached after 3 telephone calls, and 6 patients did not give a telephone number. Of the remaining 15 patients, 5 were diagnosed at the initial visit as having experienced DV, and 10 admitted on the follow-up call that the visit had been related to DV or emotional stress at home. CONCLUSION: A structured interview, conducted via telephone in follow-up of released ED patients, identified an additional 10 victims out of 142 high-risk presentations and 1,500 total ED presentations. This approach is labor-intensive, with a relatively low yield. Nonetheless, prospective identification of selective high-risk cases by physicians, coupled with subsequent social service telephone contact, may be a complement in department case finding.

Treatment of moderate-to-severe hypothermia in an urban setting.

STUDY OBJECTIVES: To study the treatment of moderate-to-severe hypothermia using a combination of core rewarming techniques. DESIGN: A prospective study. SETTING: The emergency department of an urban, community hospital. TYPE OF PATIENTS: Sixteen patients who presented with accidental hypothermia with a core temperature of less than 32 C. INTERVENTIONS: All patients were treated with warmed IV fluids either through central or peripheral IV lines and heated aerosol masks. MEASUREMENTS AND MAIN RESULTS: The patients had a mean rewarming rate of 1.16 C/hr; all survived. The majority were chronic alcoholic patients who presented with multiple medical conditions that required hospitalization. CONCLUSION: All patients recovered with this method of core rewarming.