European journal of emergency medicine : official journal of the European Society for Emergency Medicine
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Case Reports
Hyperosmolar diabetic non-ketotic coma, hyperkalaemia and an unusual near death experience.
Generally, cardiac arrest due to pulseless electrical activity has a poor outcome, except when reversible factors such as acute hyperkalaemia are identified and managed early. Hyperosmolar diabetic non-ketotic coma may lead to acute hyperkalaemia. Hyperosmolar diabetic non-ketotic coma is a metabolic emergency usually seen in elderly non-insulin dependent diabetics, characterized by severe hyperglycaemia, volume depletion, altered consciousness, confusion and less frequently neurological deficit. ⋯ Hyperosmolar diabetic non-ketotic coma should be considered in any patient with altered consciousness or neurologic deficit in conjunction with hyperglycaemia. As hyperosmolar diabetic non-ketotic coma results in severe fluid depletion, electrolyte disturbance, profound hyperglycaemia and an altered mental state, the guiding principles of therapy include aggressive rehydration, insulin therapy, correction of electrolyte abnormalities and treatment of any underlying illnesses. Treatment of acute hyperkalaemia includes calcium ions, insulin with dextrose, salbutamol and haemodialysis.
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Knife-inflicted, deeply penetrating head and neck trauma is an uncommon life-threatening injury and a challenging problem. An examination of the neurovascular and systemic physical status is a first requirement and the decision as to which approach to adopt for the removal of the blade is of critical importance. Here we report a rare case of a pre-auricular stab wound with the knife blade deeply lodged in the extracranial infratemporal fossa. ⋯ The other neurological and systemic physical evaluations were normal. Simple withdrawal of the blade in the operating room did not cause serious neurovascular injury. Here we discuss and compare the expanded exposure of anatomical structures for blade removal and simple withdrawal in similar injuries.
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Survival of patients with traumatic rupture of the thoracic aorta (TRTA) depends on early surgical repair. Six cases of TRTA were treated at our institution in 7 years. Time to diagnosis was 1.5, 3, 4, 36, 91 and 140 hours (mean = 46 hours). ⋯ Significant delay in diagnosis and treatment occurred in three patients. The reasons for delay were unrecognized signs for TRTA on the initial chest X-ray, a false-negative result of transoesophageal echography and not considering the diagnosis of TRTA. The diagnosis of TRTA requires a high index of suspicion and should always be considered in victims of high impact trauma.
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Randomized Controlled Trial Clinical Trial
Intravenous magnesium is ineffective in adult asthma, a randomized trial.
Intravenous magnesium sulphate (MgSO4) has been tried in the emergency department treatment of asthma since the mid-1980s, but published reports vary as to its efficacy. The literature suggests that it may be effective in the more severely ill asthmatic. We evaluated i.v. ⋯ In moderately severe adult asthmatics, 2.0 grams of MgSO4 i.v. resulted in less improvement in peak expiratory flow compared with placebo. MgSO4 did not appear to decrease subjective dyspnoea or the hospital admission rate. This evidence does not support the use of MgSO4 in the treatment of acute asthma.
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The principles of the management of upper cervical injuries remain controversial. The specific anatomical conditions render upper cervical injuries more problematic than lower cervical injuries. Here we present and discuss our experiences with upper cervical injury, comparing them with other treatment modalities. ⋯ All patients showed stable fracture healing and experienced no additional clinical disability on follow-up after a minimum of 3 months, except one who died due to cardiac and respiratory failure. Regardless of the type of injury, indication for surgery in many cases of upper cervical injury is neurological abnormality associated with radiologically observed neural compression. It is our belief that, in the absence of both neurological abnormality and compression to neural structures observed in CT/MRI, treatment with the Philadelphia collar alone is safe, cost-effective and easily applicable for many cases of upper cervical injury.