Annals of emergency medicine
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A case of anterolateral first rib fracture produced by indirect trauma in a surfer is presented. A 17-year-old man was seen in the emergency department with the complaint of left shoulder pain that developed while he performed a so-called lay back maneuver on a surfboard. ⋯ After physical examination revealed point tenderness high in the left axilla, radiographic evaluation of the chest showed an isolated fracture of the anterolateral aspect of the left first rib. No morbidity was associated with this fracture which, when produced by other forces, can have serious sequelae.
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Management of the airway in acutely injured patients demands special skills of the emergency physician. A technique of light-guided orotracheal intubation has been described in the literature and was performed under protocol by resident physicians in an urban mobile intensive care system. The method utilizes a flexible lighted stylet to provide a guide to correct placement through transillumination of the soft tissues of the neck. ⋯ Trauma to the soft tissues in one successfully intubated patient was the only complication reported with the technique. The advantages of this method, including rapidity of intubation, ability to intubate without manipulation of the head or neck, and the apparently few complications, make it particularly attractive to emergency personnel. We conclude that guided orotracheal intubation using a lighted stylet is an effective and safe method of emergency intubation, even in the adverse prehospital environment.
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Although hypothermia has been described as an emergency in suspended animation, severe degrees of hypothermia mandate appropriate aggressive intervention. Because of cardiac instability with core temperature below 28 C, aggressive invasive rewarming by F-F partial bypass is often ideal in this setting. ⋯ If the only definite criterion for diagnosis of death in hypothermia is failure to respond to resuscitation and rewarming, successful resuscitation must carefully balance aggressive and gentle interventions. Because CPR protocols involve legal as well as medical questions, additional prospective data are especially critical for resolving controversies in the initial management of profound exposure hypothermia.
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We compared fluid delivery, both in vitro and in vivo, using various combinations of fluid sets and intravenous catheters. Administration sets were a minidrip, a maxidrip, and a blood infusion set. The catheters included 14-, 16-, 18-, and 20-gauge short catheters, 16- and 19-gauge long catheters, and an 8 French catheter introducer for flow-directed pulmonary arterial lines. ⋯ The 8 French introducer provided no additional resistance to the flow of the maxidrip or blood infusion set when used in combination with an anesthesia extension. All the other catheters slowed flow significantly. Percutaneous insertion of an 8 French catheter introducer connected to blood administration tubing allows for rapid delivery of fluids and for subsequent insertion of a Swan-Ganz catheter, which is often necessary in critically ill patients.
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Nine dogs were hemorrhaged to approximately 40% of their blood volume and then were resuscitated with a crystalloid solution (Normosol) at various flow rates. Three study groups with three dogs in each group were resuscitated at 15 mL/min/kg (Group 1), 6 mL/min/kg (Group 2), and 4 mL/min/kg (Group 3). Central venous pressure (CVP), pulmonary artery wedge pressure (PAWP), mean arterial pressure, and cardiac output (CO) were monitored during the hemorrhage and the resuscitation from shock. ⋯ Group 3 animals had a rise in CO to 5 L/min; CVP and PAWP rose to 4.5 mm Hg and 6.8 mm Hg, respectively. In this experimental shock study, infusion of crystalloids at 6 mL/min/kg appeared to result in an improved physiologic response, although no statistical difference was demonstrated. Further studies are necessary to demonstrate the optimum flow rate for resuscitation of hypovolemic shock using crystalloids.