The American journal of emergency medicine
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To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. ⋯ Data were analyzed using the Pearson's chi 2 Test, Mann-Whitney U Test, and stepwise discriminant analysis. Significance was defined as P < or = .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.
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To reduce the emergency treatment time of shock victims, resuscitation fluids can be infused into a patient via their sternum rather than through a peripheral vein. Successful use of this method requires manual infusion because available medical equipment is not capable of infusing the preferred resuscitation fluids into the sternum at the required flow rates. ⋯ The options were narrowed down to five schemes that were studied in depth. Finally, two schemes were picked, a compressed gas bag-within-a-bag design and a peristaltic design.
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Comparative Study
Diagnostic tests for occult bacteremia: temperature response to acetaminophen versus WBC count.
A cohort of 484 febrile children were examined to (1) assess the utility of temperature response to acetaminophen as a diagnostic test for occult bacteremia (OB) and (2) compare it with the white blood cell (WBC) count. For a period of 18 months, the records of all febrile children seen in the emergency department were reviewed. Testing a response to acetaminophen of a < or = 0.8 degrees C decrease in temperature, the sensitivity, specificity, and positive and negative predictive values were 47%, 74%, 12%, and 95%, respectively. ⋯ The difference was not significant (P > 0.05). The conclusion reached was that temperature response to acetaminophen has predictive values that are similar to the WBC count, and it may provide useful information. However, neither test is impressive, and the clinician cannot reliably predict which febrile children are at risk.
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Case Reports
Extracorporeal circulation in the management of severe tricyclic antidepressant overdose.
Extracorporeal circulation is a technique that provides precise control of circulation, oxygenation, temperature, and blood composition in patients suffering from cardiopulmonary failure. The investigators present the case of a near fatal tricyclic antidepressant overdose that failed to respond to standard therapy but was resuscitated using extracorporeal circulation.
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Cardiovascular deterioration after seizures in tricyclic overdose has long been suspected. The investigators studied a patient with a nortriptyline HCI level of 1,205 ng/mL who had four generalized grand mal seizures, each lasting between 60 and 90 seconds that were immediately followed by hypotension requiring norepinephrine support. When the seizures were controlled with midazolam, the hypotension subsided and norepinephrine was decreased. The metabolic acidosis associated with the seizures may have caused hypotension by direct cardiotoxicity, an increase in bioavailability of tricyclic antidepressant because of changes in protein binding, an alteration of the effects of tricyclic antidepressant on cardiac membrane sodium channels, or a combination of these mechanisms.