The American journal of emergency medicine
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A case of massive degloving injury of the trunk, with open pelvic fracture, and evisceration of abdominal contents from blunt trauma is presented. The most significant aspect of this case was the transfusion of 173 units of packed cells and 176 units of fresh frozen plasma in the first thirty hours. The patient ultimately recovered and returned to work.
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An 80-year-old man was treated, non-operatively, for a distal esophageal perforation, diagnosed nine days after blunt thoracic trauma. Emergency department diagnosis was impeded by absence of mediastinal air; right chest-wall emphysema was thought to result from associated rib fractures. ⋯ This mode of therapy may be best in comparable elderly patients with esophageal perforation that is overlooked during the initial 24 hours after injury. Possibly, routine barium swallow in all patients with chest-wall emphysema and rib fractures would circumvent missed esophageal rupture after blunt trauma.
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An unusual case of a misdirected nasogastric tube is described. An elderly woman was brought to an emergency department following intentional drug overdose. Initially unrecognized errant placement of a large-bore nasogastric tube resulted in tension pneumothorax, pneumonia, and subsequent death. Pertinent medical literature is reviewed, clinical considerations for the elderly patient are discussed, and suggestions for proper nasogastric tube placement are offered.
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Intraosseous infusions were widely used in pediatric patients during the 1930s and 1940s. Recent reports have re-introduced this concept and confirmed its safety and ready accessability for fluid and drug administration. However, these reports have not addressed the difficulties encountered during insertion of the intraosseous needle. ⋯ This method was successfully utilized in ten pediatric and five adult patients. Intraosseous needle placement is a safe, rapid method to gain access to the venous circulation. By utilizing these techniques, a stable, usable fluid line can be established in even the most dehydrated pediatric patients.
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Boerhaave's syndrome represents a diagnostic dilemma for the emergency physician. The prognosis of this truly life-threatening emergency is darkened by any significant diagnostic delay. Unfortunately, classic or expected symptoms and signs are frequently absent at presentation, a circumstance that leads to frequent misdiagnosis. ⋯ However, emphasis should be placed on the fact that this entity may occur without emesis. The chest radiograph is the most helpful diagnostic aid. Undoubtedly, maintenance of a high degree of suspicion by the emergency physician for Boerhaave's syndrome will lead consistently to earlier diagnosis, and subsequent aggressive intervention should result in considerable reduction in rates of both morbidity and mortality.