J Emerg Med
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Patients with internal herniation after Roux-en-Y gastric bypass might present with normal laboratory values, minimal physical examination findings, and nonspecific radiographic results, making early diagnosis difficult and resulting in catastrophic bowel necrosis. ⋯ The occurrence of Petersen's hernias has increased with laparoscopic Roux-en-Y gastric bypass due to less postoperative adhesions. Whether days or several years after gastric bypass, patients with intermittent abdominal pain, nausea, or vomiting need to be carefully evaluated. These herald signs of internal herniation should prompt early surgical consultation. Pain out of proportion to physical examination often indicates need for urgent surgical intervention. Physicians need to be educated about this potentially life-threatening complication so early diagnosis and treatment can avoid catastrophic bowel gangrene.
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Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. ⋯ The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.
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Case Reports
Recurrent Posterior Reversible Encephalopathy Syndrome in a Pediatric Patient With End-stage Renal Disease.
Posterior reversible encephalopathy syndrome (PRES) is a condition manifested by altered mental status, seizures, headaches, and visual loss. Specific abnormalities are seen by computed tomography or magnetic resonance imaging. Awareness of this syndrome is important for Emergency Physicians because visual loss can be reversible with prompt treatment of the underlying cause. ⋯ PRES should be considered in all patients presenting to the ED with visual loss, seizures, or headache, and can be recurrent in some individuals. Prompt treatment can help prevent permanent vision loss.
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Acute i.v. treatment for pediatric headache varies widely. ⋯ In our case series, adolescents given i.v. magnesium as an abortive therapy for headache experienced minimal side effects and further studies should evaluate for effectiveness.
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Low-molecular-weight heparin (LMWH) is increasingly being prescribed for prophylaxis and treatment of thromboembolic diseases. Despite the fact that its therapeutic use is considered to be safe, it can be complicated by major hemorrhage and, in contrast to unfractionated heparin, it can only partially be neutralized by protamine. Recent reports of LMWH overdose illustrate the need for a consensus on its management. ⋯ In this case of massive tinzaparin overdose, conventional doses of protamine failed to rapidly normalize the deranged coagulation parameters. The favorable clinical outcome suggests that, regardless of the LMWH amount injected, no active treatment is needed in the absence of hemorrhage. This is in accordance with the limited published data concerning cases of overdose with other LMWHs.