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 19,632 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Patients with chronic renal failure (CRF) are at risk for unique medical emergencies, many of which require hemodialysis for their definitive treatment. This study describes the use of emergency department (ED) hemodialysis in the management of CRF patients. A retrospective chart review was conducted of patients who underwent ED hemodialysis at a regional dialysis center between April 1994 and September 1996. Data were collected on presenting complaint, ED diagnosis, indication for hemodialysis, ED pharmacologic treatment, ED airway management, cardiovascular stability, and disposition. Fifty episodes of ED hemodialysis were identified in 37 different patients. Presenting complaints included: shortness of breath, 38 (69%); weakness, 8 (15%); chest pain, 3 (5%); and other, 6 (11%). ED diagnoses included: congestive heart failure, 36 (65%); hyperkalemia, 13 (24%); and other, 6 (11%). Indications for hemodialysis included: cardiovascular instability, 33 (38%); respiratory distress, 22 (26%); cardiac monitoring, 16 (19%), timing, 13 (15%); and other, 2 (2%). Predialysis stabilization included: nitroglycerin, 29 (26%); sublingual captopril, 17 (15%); calcium chloride, 13 (11%); sodium bicarbonate, 12 (11%); insulin/dextrose, 11 (10%); none, 12 (11%); and other, 18 (16%). Airway support included: noninvasive pressure support ventilation (NPSV), 9 (18%); and endotracheal intubation, 6 (12%). NPSV was provided with a bilevel positive airway pressure system. Three of the endotracheal intubation patients were weaned to NPSV during dialysis, and all NPSV patients were weaned from respiratory support during their hemodialysis in the ED. Some patients had more than one problem. Sixteen patients (32%) were admitted, while 34 (68%) were discharged, including 3 NPSV patients and 22 initially unstable patients. ED hemodialysis in conjunction with additional medical care is a useful emergency medicine technique that can prevent hospital admission in patients with acute renal emergencies.
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PMID:ED hemodialysis for treatment of renal failure emergencies. 1033 96

There are three clinical presentations of anthrax in humans: cutaneous (>95% of cases), orogastric and inhalational. The infectious form, the spore, enters the body and is thought to germinate within macrophages either at the site of inoculation (cutaneous or orogastric) or in the regional lymph node (inhalational). The bacillus then synthesizes its antiphagocytic capsule and the lethal and oedema toxins which interfere with the non-specific host defences leading to the characteristic locally destructive lesion and spread by lymphatics to the systemic circulation and other organs. The cutaneous form begins as a papule which progresses over several days to a vesicle and then ulcerates. There is often oedema, sometimes massive, probably due to the oedema toxin that surrounds the lesions which then develop a characteristic black eschar. The patient may be febrile with mild to severe systemic symptoms of malaise, headache and toxicity. Oropharyngeal anthrax presents with severe sore throat or an ulcer in the oropharyngeal cavity associated with neck swelling, fever, toxicity and dysphagia. Gastrointestinal anthrax begins with anorexia, nausea, vomiting and abdominal pain which may be similar to an acute abdomen. There may be diarrhoea and ascites, both of which may be haemorrhagic. Inhalational anthrax begins with non-specific symptoms of malaise, fever, myalgia and non-productive cough. After a period of 2-3 days, this is followed by a sudden onset of severe respiratory distress associated with diaphoresis, cyanosis and increased chest pain. There may be a widened mediastinum and pleural effusions on chest X-ray. Death follows in 24-36 h from respiratory failure, sepsis and shock. The diagnosis of anthrax is easy if it is considered. The organism is readily observed by Gram or Wright stain in local lesions or blood smear and can be easily cultured from the blood and other body fluids. However, because of its rarity, it is not often included in the differential diagnosis and in inhalational disease the diagnosis is rarely made until the patient is moribund. More rapid diagnostic tests are under development. Penicillin, combined with supportive care, remains the mainstay of treatment, although the organism is susceptible in vitro to many antibiotics. In recent years, there have been significant advances in our knowledge of the organism and its toxins and it is anticipated that similar progress will be made in the future in developing more rapid diagnostic tests and new modalities of treatment.
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PMID:Clinical aspects, diagnosis and treatment of anthrax 1047 74

Jessica, a 14-year-old girl with a history of asthma, went to her pediatrician's office because of a persistent cough. She had been coughing for at least 3 months with occasional cough-free periods of less than a few days. The cough was nonproductive and was not accompanied by fever, rhinorrhea, or facial or chest pain. Jessica and her mother observed that the cough increased with exercise and typically was not present during sleep. She has used two metered-dose inhalers--albuterol and cromolyn--without any change in the cough pattern. For the past 5 years, Jessica has had mild asthma responsive to albuterol. She enjoys running on the cross-country team, soccer, and dancing. She is an average student and denies any change in academic performance. She has never been hospitalized or had an emergency department visit for asthma or pneumonia. There has been no recent travel or exposure to a person with a chronic productive cough, tobacco smoke, or a live-in pet. Jessica lives with her mother and younger sister in a 10-year-old, carpeted apartment without any evidence of mold or recent renovation. In the process of taking the history, the pediatrician noticed that Jessica coughed intermittently, with two or three coughs during each episode. At times, the cough was harsh; at other times, it was a quiet cough, as if she were clearing her throat. She was cooperative, without overt anxiety or respiratory distress. After a complete physical examination with normal findings, the pediatrician interviewed Jessica and her mother alone. Jessica's parents had been divorced for the past 6 years. She lived with her mother but visited her father, and his new family with two young children, every weekend. She spoke about this arrangement comfortably and said that she loved her father and mother but didn't like the tension she experienced at her father's home. "I don't like adults arguing when kids are around." When asked why she thought the cough persisted so long, she commented in a neutral tone, "I don't know. It's never been like this before." Jessica's pediatrician prescribed an inhaled steroid with the albuterol. When the cough did not respond after 1 week, he ordered a chest radiograph (normal) and a tuberculin skin test (purified protein derivative-negative), and he added montelukast (a leukotriene inhibitor) and monitored airway resistance with a peak flow meter. The cough persisted, and the peak flow recording showed normal airway resistance. At this time, Jessica's pediatrician suspected a conversion reaction and contemplated the next best therapeutic strategy.
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PMID:Persistent cough in an adolescent. 1060 74

We report two pediatric patients with end-stage renal failure who developed heparin-induced thrombocytopenia type II (HIT II) on hemodialysis (HD). Both developed acute respiratory distress and chest pain within 30 min of initiating the 5th HD session. The platelets dropped during HD from 168 to 38x10(9)/l and from 248 to 109x10(9)/l, respectively. Marked clots were observed in the dialyzers. Substitution of heparin with the low molecular weight heparin dalteparin had no effect. Switching from anticoagulation to the heparinoid danaparoid resulted in immediate disappearance of all adverse effects, and further long-term HD was uneventful. HIT II was diagnosed clinically; heparin-induced platelet activation test (HIPA) and serum IgG, IgA, and IgM to heparin-platelet factor 4 complexes (HPF4) were both negative. We conclude that HIT II may occur in children on HD. HIT II is essentially a clinical diagnosis, as HIPA and antibodies to HPF4 are not always positive. Once HIT II is suspected, heparin (and low-molecular-weight heparins) should be stopped immediately. Long-term anticoagulation with danaparoid is a valuable option for patients on HD.
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PMID:Heparin-induced thrombocytopenia type II on hemodialysis: switch to danaparoid. 1095 13

The objective of this study was to examine the percent of spontaneous pneumomediastinums (SPM) as a complication of asthma in children and adolescent, and to examine the symptoms and clinical signs which predict SPM. A retrospective analysis was performed of patients discharged from Srebrnjak Hospital between 1988 and 1991 with the diagnoses of asthma and SPM. Ten cases (8 males and 2 females) aged 4-19 years were compared with 50 hospitalized patients. SPM was found in 4.96% of patients. Mean age of patients with SPM and asthma was 11.2 and of control patients 11.45 years. Chest pain was reported in 5/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). Subcutaneous emphysema was detected in 9/10 patients with SPM and asthma and in 0/50 of controls (p < 0.01). There was no difference in respiratory distress, partial oxygen pressure and oxygen saturation, heart rate and respiratory rate between cases and controls (p > 0.05). Systolic pressure was higher in children with SPM, but the values were within normal limits. During hospitalization in 3 patients with SPM partial left pneumothorax developed, in 1 partial bilateral pneumothorax and in 2 pneumopericardium. Subcutaneous emphysema is a significant specific clinical sign, and chest pain is a predominant symptom in the diagnosis of SPM. The patients with asthma and SPM must be treated in hospital because of potential further complication.
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PMID:[Spontaneous pneumomediastinum as a complication of asthma in adultsand adolescents]. 1104 58

Pulmonary blastoma (PB) is a rare malignant pulmonary tumor composed of immature mesenchyme and/or epithelium that resembles an embryonic lung at 10-16 weeks gestation. PBs constitute only 0.25 to 0.5 percent of all primary malignant lung tumors. Approximately 20 percent of the reported cases have occurred in pediatric patients. A seven-year-old girl presented with fever, cough, respiratory distress and chest pain on the left side. An x-ray, ultrasonography and a computed tomographic scan of the chest showed a large mass consisting of solid and cystic components almost completely occupying the left hemithorax associated with pleural effusion. The diagnosis of biphasic PB was established by histological examination of thoracotomy material. The patient was considered inoperable due to tumor involvement of the mediastinum, and she died two days after the initiation of chemotherapy. We report this case of PB to raise attention to the clinical, radiological and pathological features of PB in childhood because of its rarity.
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PMID:Biphasic pulmonary blastoma in a child. 1110 32

The authors report on two female patients aged 12 and 14 years, who spontaneously developed a rupture of benign mediastinal cystic teratoma into the right pleural cavity. They presented with acute onset of severe chest pain and respiratory distress. The tumors were completely resected by thoracotomy. The serum and pleural fluid levels of carcinoembryonic antigens, CA-125 and CA19-9 were invariably elevated, then decreased to normal range after the surgical resection. Rapid diagnosis of this extremely rare complication is important because it may progress to a life-threatening condition.
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PMID:Spontaneous rupture of mediastinal cystic teratoma into the pleural cavity: report of two cases and review of the literature. 1129 92

We present the case of a 69-year-old man with a history of hypertension and a recent pelvic fracture who presented with acute chest pain, shortness of breath, and severe hypotension. The history of recent pelvic fracture and the clinical manifestations, including the sudden onset of acute respiratory distress, hypotension, and hypoxemia, indicated pulmonary embolism; however, at surgery the patient was found to have an acute dissection of the ascending aorta with obstruction and thrombosis of the right pulmonary artery. This case emphasizes the need to consider such a diagnosis in patients who have unilateral absence of perfusion to the right lung.
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PMID:Acute dissecting aneurysm of the ascending thoracic aorta causing obstruction and thrombosis of the right pulmonary artery. 1145 30

The purpose of the Emergency Medical Services Outcomes Project (EMSOP) is to develop a foundation and framework for out-of-hospital outcomes research. In prior work (EMSOP I), discomfort had the highest weighted score among outcome categories for the top 3 adult conditions (ie, minor trauma, respiratory distress, chest pain) and the first and third highest rankings for children's conditions (ie, minor trauma, respiratory distress). In this fourth article in the EMSOP series, we discuss issues relevant to the measurement of pain in the out-of-hospital setting, recommended pain measures that require evaluation, and implications for outcomes research focusing on pain. For adults, adolescents, and older children, 2 verbal pain-rating scales are recommended for out-of-hospital evaluation: (1) the Adjective Response Scale, which includes the responses "none," "slight," "moderate," "severe," and "agonizing," and (2) the Numeric Response Scale, which includes responses from 0 (no pain) to 100 (worst pain imaginable). The Oucher Scale, combining a visual analog scale with pictures, seems most promising for out-of-hospital use among younger children. Future research in out-of-hospital care should be conducted to determine the utility and feasibility of these measures, as well as the effectiveness of interventions for pain relief.
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PMID:Emergency Medical Services Outcomes Project (EMSOP) IV: pain measurement in out-of-hospital outcomes research. 1214 Apr 96

Re-expansion pulmonary oedema is a well-recognized rare complication of the treatment of spontaneous pneumothorax. It has been associated with death in 20% of cases. A fit 20-year-old man who had returned from holiday 2 days previously presented with a large left-sided pneumothorax of 10 days' duration. He had exhibited symptoms of chest pain and shortness of breath during the return flight. He showed no signs of respiratory distress at presentation to the Accident and Emergency Department, but after treatment with a chest tube in the ensuing 90 min developed severe unilateral re-expansion pulmonary oedema and circulatory collapse. Factors in the aetiology of the condition and prevention are considered.
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PMID:Re-expansion pulmonary oedema and circulatory shock in a 20-year-old man. 1278 75


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