Pneumomediastinum acquired by glass blowing.

Pneumomediastinum is uncommon. We present a case of spontaneous pneumomediastinum, which occurred in a young man whose profession is glass blowing. He presented not only with typical complaints of chest pain and odynophagia, but also with the unusual complaint of a "foreign body" sensation in the middle of his chest.

Wound infection due to fresh water contamination by Aeromonas hydrophila.

We report the case of a 24-year-old man who sustained a scalp laceration in a diving accident. His wound became infected, and he was treated with an oral cephalosporin, with subsequent progression of the infection. Cultures subsequently grew Aeromonas hydrophila. Many strains of Aeromonas are not sensitive to the antibiotics commonly used for wound infections. Aeromonas must be suspected as a pathogen in all wounds occurring in fresh water if proper treatment is to be initiated.

Abdominal aortic aneurysm rupture presenting as testicular pain.

We report the case of a 74-year-old man who presented to our emergency department with complaints suggestive of a urinary tract disease. After examination failed to reveal another etiology for his symptoms, antibiotic therapy was initiated and the patient was discharged. He returned the next day with worsening pain; he was reevaluated and given an injection to control his pain. Thirty seconds later, the patient was unresponsive and pulseless and died despite resuscitative efforts. Autopsy revealed a ruptured abdominal aortic aneurysm. Our case highlights the varied presentations of abdominal aortic aneurysm, which often go unrecognized, and the need to diligently search for this life-threatening affliction.

Emergency department experience with sudden death: a survey of survivors.

Sudden death in the emergency department occurs frequently. Intervention by ED support staff may have a significant impact on the survivor's grief response. This study was undertaken to assess sudden death survivors' perceptions and satisfaction with their ED experience, as well as to identify potential weaknesses in their management. Family members of 66 patients who died in the ED from January 1980 to March 1985 were surveyed by telephone interview regarding the care they, as survivors, received while in the ED. Forty-seven of 66 (71%) were satisfied, 19 of 66 (29%) believed that their family received average or worse than average care. Thirty-seven of 66 (56%) survivors viewed the deceased in the ED; five regretted this. Twenty-nine survivors did not view; seven (24%) had regrets. Participants were questioned about attitudes expressed by the ED staff. Most responses were favorable, but a significant number thought the staff cold, unsympathetic, and not reassuring. Areas of apparent survivor dissatisfaction are discussed.

Ventricular fibrillation during orotracheal intubation of hypothermic dogs.

Physical manipulation of the hypothermic patient is well known to cause ventricular fibrillation. Careful review of the literature fails to demonstrate a true temporal relationship between orotracheal intubation and ventricular fibrillation (VF) when acceptable temperature-corrected arterial blood gases have been obtained. Eleven mongrel dogs were anesthetized and cooled, with orotracheal intubation and extubation performed every two degrees centrigrade, starting at 27 C. Ventilator setting were adjusted to maintain normal pH according to arterial blood gases drawn every two degrees and corrected for temperature. There was only one episode of VF during 42 intubations performed at temperatures less than 28 C (2.38%). There were eight separate episodes of spontaneous VF unrelated to intubation in five dogs. Four of these five with spontaneous VF were resuscitated with countershock only, further cooled, and reintubated an additional 11 times without a single episode of VF during intubation. Our data suggest that the incidence of VF during intubation in the hypothermic patient is much less than previously described, provided that normal pH is maintained and hypoxemia is corrected.

Emergency medicine and surgery resident roles on the trauma team: a difference of opinion.

Although many emergency medicine residency programs are located in major trauma centers, trauma often is managed by a multispecialty team. In order to define the role of the emergency medicine resident at such centers, we sent surveys to the directors of all 64 approved emergency medicine residency programs. Of the 54 programs (84%) responding, 39 (72%) had trauma teams. Trauma team composition varied widely. Only 54% included general surgery staff physicians, and 38% included an anesthesiologist. Ninety percent of the teams included an emergency medicine resident. Overall emergency medicine residents serve as trauma captains 50% of the time and share the role with a general surgery resident 23% of the time. With the exceptions of peritoneal lavage and intubation, resuscitation procedures were shared between the general surgery and emergency medicine residents. Thirty-one percent of the respondents had air ambulances, 70% of which were staffed by emergency physicians. We conclude that emergency medicine residents are active trauma team leaders and providers.

Intraosseous infusions in the emergency department.

For most emergency physicians and pediatricians, the frustrations encountered when obtaining intravenous access in infants involved in traumatic or medical emergencies are well known. Although it is rare that parenteral access is absolutely unobtainable in a pediatric patient, minutes and sometimes hours are often lost as futile attempts are made to cannulate a collapsed vein of such a patient. Many alternatives to such a crisis situation, including the intratracheal, intracardiac, and sublingual routes of administration, have been proposed and efficaciously used. Disadvantages to these alternatives, however, include the inability to administer volume-expanding colloids or crystalloids, and a relatively narrow spectrum of useful medications. One relatively safe, well-proven, and technically easy method for giving replacement fluids, blood products, and numerous resuscitative drugs is infusion by the intraosseous route. Although not recommended as a replacement for current modes of intravascular access, we feel it has definite utility in selected situations and warrants the awareness of emergency physicians. The value, historical aspects, technique, and complications of this procedure are discussed.

Osteomyelitis of the cervical spine: reversible quadraplegia resulting from Philadelphia collar placement.

Pyogenic osteomyelitis of the vertebrae accounts for 4% of all osteomyelitis, and is believed to be increasing in incidence. Pyogenic osteomyelitis of the cervical spine is even more uncommon, accounting for 10% of all spinal pyogenic osteomyelitis. Presented is a case of pyogenic osteomyelitis of the cervical spine in which appropriate methods of immobilization of the cervical spine resulted in a surgically reversible acute deterioration of the patient's neurologic status. While immobilization of the cervical spine remains the initial treatment of choice in most patients with suspected disease of the cervical spine, it is not without potential complications.

Bilateral posterior fracture-dislocations of the shoulder after convulsive status epilepticus.

Presented is the case of a 30-year-old man who sustained bilateral posterior fracture-dislocations of the shoulder as an unusual complication of status epilepticus. Initial evaluation failed to reveal this unsuspected diagnosis. After improvement in the patient's mental status, his subjective complaints made the diagnosis evident. He subsequently underwent hemiarthroplasty for one shoulder and active assisted range of motion exercises for the other, with partial return of function in both arms.

Lidocaine toxicity following subcutaneous administration.

A case of a 2-year-old girl who survived grand mal seizures secondary to toxicity from massive subcutaneous administration of lidocaine is presented. She was treated with intravenous diazepam and was intubated. After 24 hours of observation she was discharged, and there have been no sequelae or recurrence of seizure activity during ten months follow up. Central nervous system, cardiac, and hematologic effects of lidocaine toxicity are discussed. Drug interactions that may potentiate lidocaine toxicity are listed.

The scavenger device for nitrous oxide administration.

Nitrous oxide levels of 300 to 500 ppm occur when nitrous oxide is administered in the emergency department using the Nitronox machine without use of the scavenger device, which traps expired nitrous oxide gases and vents them to the outside environment. A scavenger device that can limit nitrous oxide gas to zero ppm in the emergency department setting has been developed. We think that development of the scavenger device is a significant advance for the safe administration of nitrous oxide in the emergency department.

The spectrum of toxic shock syndrome.

The toxic shock syndrome (TSS) is a newly-recognized entity caused by a Staphylococcal exotoxin and associated with the use of tampons for menstrual protection. Two cases are presented which demonstrate the spectrum of severity of the disease. The common nature of its early symptoms necessitates a high index of suspicion to preclude a progression to the later stages of the disease, thereby reducing morbidity and mortality.

Radiation exposure of emergency physicians.

Radiation exposure was prospectively measured using film dosimeters worn at the lapel and dominant wrist for up to three two-month intervals in 18 emergency physicians and residents, and was compared to that received by 18 radiology technicians and 18 first-year house staff during similar periods. While all levels were well below maximum permissible doses for occupational exposure, the mean lapel exposures for a two-month period were 14 mrem for the emergency physicians, 26 mrem for radiology technicians, and 7 mrem for the house staff. The difference between the latter two was statistically significant. At the wrist, emergency physicians had a mean of 43 mrem; radiology technicians, 25 mrem; and house staff, 5 mrem. The difference between the first and third groups was statistically significant. No correlation between number of exposures and exposure levels could be detected because of variation in use of protective garments, distance from the beam, and type of exposure. Procedures requiring personnel exposure include those of small children, stress views of the extremities, and studies in the multiply traumatized patient.

The rural interhospital disaster plan: some new solutions to old problems.

The rural area is not immune to multi-casualty incidents, and the complete rural EMS System reported here includes a plan to deal with one. The Susquehanna Valley Health Care Consortium was developed with this in mind, and addresses the points pertinent to the rural setting, including the large area served, available medical care, prehospital transport, and communications. Six hospitals in five counties participate. New approaches to these problems, which emerged after three field tests, are: participants must be organized for successful triage and resuscitation; crowd and traffic control by police is mandatory; an overall commander is necessary; two-way communication by several methods must be available; an administrator should track all victims; and air evacuation capability should be arranged.

Nitrous oxide levels in the emergency department.

Levels of nitrous oxide were monitored in the emergency department during the use of a Nitronox machine after four and eight minutes of breathing gas. Levels near the user's head were found to be 800 to 1,200 parts per million. Levels at the center of the room peaked at 300 ppm after eight minutes of use, and spot checks in the emergency department hall adjacent to the test room were less than 10 ppm. Ventilation was measured in the test room and was found to influence the peak level of nitrous oxide and the rapidity of washout of the gas from the room. The results of this study should prompt the development of guidelines for the use of nitrous oxide in the emergency department setting.

Lidocaine toxicity.

Lidocaine is recognized as a first line drug for ventricular arrhythmias and has recently been used in acute myocardial infarction as prophylaxis against ventricular fibrillation. A 68-year-old man was erroneously given 2 gm of lidocaine by intravenous push and sustained a cardiac arrest. He was treated supportively and had complete recovery. We discuss complications of therapeutic and excessive doses of lidocaine and outline measures for treatment of massive lidocaine overdose.

The weak and dizzy patient.

The weak and dizzy patient presents a dilemma for the emergency physician. Because of the non-specificity of symptoms, the physician is often faced with uncertainty as to how to initiate his evaluation. This retrospective study examines the case histories of 106 consecutive patients who presented with the chief complaints of weakness and/or dizziness. Weak and dizzy patients over the age of 60 had a greater incidence of potentially serious and treatable disease. Twenty percent of this age group had symptoms directly attributable to prescribed medications.