The management of cyclic vomiting syndrome: a systematic review

Cyclic vomiting syndrome (CVS) is a rare abnormality of the neuroendocrine system that affects 2% of children. It is a frequently missed diagnosis in the emergency department and may require a number of emergency department visits before the diagnosis is made. The objectives of this review are to identify the clinical features that suggest a diagnosis of CVS and to review the literature on its management. The MEDLINE and EMBASE databases were searched from January 1948 to October 2011 using the keywords 'Cyclic' or 'Vomiting'. Papers were excluded if they did not follow the consensus guidelines or if they were case reports. This review analysed 1093 cases of cyclic vomiting in 25 papers that fulfilled the inclusion criteria. All except one paper were retrospective studies. The size of these cohort studies ranged from three to 181 patients, with a mean patient size of 29. This review found that over 40% of patients have headaches/migraines, with associated anxiety and depression in ≈ 30% of cases. There is a family history of headaches/migraines in 38.9%, and this association was much stronger in the adult CVS cohort compared with the paediatric cohort. Compared with paediatric CVS, adults have a longer duration of attacks and they occur more frequently (5.9 vs. 3.4 days, 14.4 vs. 9.6 episodes/year). Limited data are available on the treatment of the acute phase of CVS, but in adults, sumatriptan has been shown to be effective. For prophylactic treatment, tricyclics are effective in both adult and paediatric CVS, with a clinical response in 75.5 and 67.6% of patients, respectively, in nonplacebo-controlled cohort studies. Furthermore, propranolol has been shown to be useful in children. CVS is an intractable illness with a major impact on the patient's quality of life. There is a long duration between the onset of symptoms and the diagnosis of the condition. There is a high association with headaches/migraines and anxiety/depression. The symptoms are more severe in adult-onset CVS. Tricyclic antidepressants have good efficacy in reducing the frequency/duration or the intensity of attacks. There is limited evidence on the acute management of CVS.     

Acute coronary syndromes in the emergency department: diagnostic characteristics, tests, and challenges

Failure to diagnose patients who have acute coronary syndromes (ACSs)-either acute myocardial infarction (AMI) or unstable angina pectoris (UAP)-who present to the emergency department (ED) remains a serious public health issue. Better understanding of the pathophysiology of coronary artery disease has allowed the adoption of a unifying hypothesis for the cause of ACSs: the conversion of a stable atherosclerotic lesion to a plaque rupture with thrombosis. Thus, physicians have come to appreciate UAP and AMI as parts of a continuum of ACSs. This article reviews the state of the art regarding the diagnosis of ACSs in the emergency setting and suggests reasons why missed diagnosis continues to occur, albeit infrequently.     

Obere Einflussstauung

Superior vena cava syndrome is due to extrinsic compression or obstruction of the superior vena cava. Cancer especially lung cancer and malignant lymphomas are the most common underlying causes. In rare cases of benign etiology you can also find thrombosis. Typical symptoms are neck swelling and distended veins over the chest, but also very serious symptoms like respiratory failure, cerebral edema, or seizures can occur. Symptoms depend on the grade of caval obstruction and time for development of obstruction. CT scan is required for diagnosis. Before starting treatment it is advantageous to establish a histologically proven diagnosis. Treatment options include radiotherapy or chemotherapy depending on the underlying diagnosis. A new effective option in management of superior vena cava syndrome is endovascular stenting. A few hours after stent implantation symptomatic improvement can be seen. This procedure is recommended especially in emergency settings. Only in cases of emergency can irradiation be started without pathologically proven diagnosis.     

Evaluación y manejo de emergencias en el paciente con cirrosis

The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.     

Survey of British Columbia cardiologists' and emergency physicians' practice of using nonstandard ECG leads (V4R to V6R and V7 to V9) in the diagnosis and treatment of acute myocardial infarction.

BACKGROUND: There is evidence that the addition of nonstandard electrocardiographic (ECG) leads results in significant increases in sensitivity for the diagnosis of acute myocardial infarction compared with the standard 12-lead ECG. OBJECTIVE: To examine how cardiologists and emergency physicians in British Columbia use nonstandard ECG leads (V4R to V6R and V7 to V9) in the diagnosis and treatment of acute myocardial infarction. DESIGN: A list of fax numbers of all cardiologists and emergency physicians in British Columbia was obtained and questionnaires were then transmitted. MAIN RESULTS: More than 75% of cardiologists and emergency physicians correctly identified the diagnostic criteria for acute right ventricular and posterior myocardial infarction. More than 70% of surveyed physicians reported that they would use the 18-lead ECG regularly if they could gain an increased sensitivity for the diagnosis of acute myocardial infarction. However, fewer than 20% of all surveyed physicians reported regular use of the 18-lead ECG. Furthermore, the survey determined that the majority of physicians would alter their choice of thrombolytic if they could diagnose right ventricular infarction complicating an inferior infarction. Finally, most physicians reported that they would treat an isolated posterior wall myocardial infarction with a thrombolytic. CONCLUSIONS: This study suggests most cardiologists and emergency physicians in British Columbia are aware of 18-lead ECG diagnostic criteria for acute right ventricular and posterior wall myocardial infarction. Furthermore, these physicians would be willing to use this tool if it were to increase diagnostic sensitivity for acute myocardial infarction. Despite these findings, only the minority of surveyed physicians use this tool regularly.     

Informed consent for clinical research in the emergency department

Informed consent serves as the basis for a partnership between patients and physicians as they attempt to find better methods of diagnosis and treatment. Despite the importance of informed consent, this is an area of research that is frequently overlooked. In fact, an improperly designed consent form is the most common reason research protocols are rejected or approval is delayed. The essential elements of informed consent and problems obtaining informed consent from patients is an emergency department are reviewed.     

Hyperlipidemias, lipid storage disorders, metal storage disorders, and ochronosis

This review presents up-to-date information on many unusual causes of musculoskeletal disorders. These disorders are grouped together because in each there is abnormal accumulation of normal materials or accumulation of abnormal materials in cells or interstitial tissues. Most of these conditions or their associated musculoskeletal manifestations are rare. However, they may present to the adult or pediatric rheumatologist for diagnosis or therapy or both. Gout, because of its prevalence, has been excluded from this review, but it is included briefly in the discussion of the specific arthritides associated with hyperlipidemias. Disorders associated with abnormal lipid storage in which bone and joint pathology occur frequently include Gaucher's disease, histiocytosis-X, and multicentric reticulohistiocytosis. The rarer disorders of this type discussed are Fabry's disease, sea-blue histiocytosis, and Farber's disease. The abnormal accumulation of metal ions in hemochromatosis and in Wilson's disease are probably causative, either directly or indirectly, in the musculoskeletal features of these diseases, while in ochronosis, calcium crystal deposition accompanies the cartilage degradation characteristic of this disease.     

Clinical picture of diverticular disease of the colon

Uncomplicated diverticular disease is usually asymptomatic. When abdominal pain or discomfort related to defecation, altered bowel habit, and flatulence occur, they are likely a result of a coexistent irritable bowel. Nonetheless, diverticula are subject to serious complications. Diverticular hemorrhage may be massive and require emergency angiography and segmental resection. Peridiverticulitis occurs when a diverticulum ruptures, perhaps because of inspissated fecal material. This occurs usually in the sigmoid, resulting in a peridiverticular abscess localized by the adjacent fat and mesentery. If the infection extends beyond this, abscess, fistula, or free perforation may occur. These complications require antibiotics, intravenous therapy, and, in the case of uncontrollable abscess or perforation, urgent surgery. Obstruction of the colon, sometimes associated with ileus, may occur and in this case one may find a carcinoma among extensive diverticular disease. Although there is insufficient evidence to justify a high-fiber diet for the general population, the notion of a low-residue diet in the management of uncomplicated diverticular disease should be laid to rest.     

急诊糖尿病酮症酸中毒误漏诊临床分析

目的提高对急诊不典型糖尿病酮症酸中毒的认识,减少误漏诊的发生。方法收集近4年来该院急诊科收治的22例糖尿病酮症酸中毒病例资料,对其中4例误诊漏诊病例临床资料进行回顾性分析。结果22例病例中出现4例误诊漏诊,误诊漏诊率为18．2％。4例误诊漏诊患者人院时主诉均未提及糖尿病病史,此次发病时间短,来诊时无典型糖尿病酮症酸中毒症状、体征。结论对急诊患者,要加强病史询问,全面体检,加强血糖、血生化、尿生化检查,可降低糖尿病酮症酸中毒误诊漏诊率。     

Ovarian teratoma in a teenager causing ureterohydronephrosis: Case report and literature review

Rationale:Teratomas are solid tumors that may occur in both gonadal and extragonadal locations, depending on the age of the child. Benign cystic teratomas are relatively common tumors among women of reproductive age, but they can occur at any age. The clinical presentation is not specific. They can be found incidentally when patients are investigated for other conditions or they can present as emergencies when the ovarian teratoma is torsioned or ruptured.Patient concerns:We present the case of a 17-year-old adolescent girl that was seen in our emergency department on several occasions for recurrent episodes of abdominal pain ongoing for 6 months.Diagnosis:An ultrasonography (US) was performed as an outpatient and a left ovarian mass was found along with right ureterohydronephrosis (UHN). Further assessment of the mass was done by abdominal and pelvic CT and tumoral markers. CT appearance was more suggestive of a teratoma.Interventions:She underwent laparotomy with complete excision of the tumor.Outcome:The patient had an uneventful recovery. A renal US follow up showed reduction of the dilatation, demonstrating that the condition was secondary to tumor compression.Lessons:In a teenager with nonspecific symptoms, a high suspicion index for tumors is mandatory. An early diagnosis and management avoid complications like UHN.     

Rare case of omentum-wrapped abscess caused by a fish bone penetrating the terminal ileum

Accidentally ingested foreign bodies, for the most part, pass through the gastrointestinal tract, but can cause several complications. Perforation is rare, but can occur in any segment of the gastrointestinal tract. Intestinal perforations due to foreign bodies are rarely diagnosed preoperatively as clinical symptoms are non-specific and they can mimic other abdominal conditions. We describe a case of a 48-year-old patient who was admitted to the emergency room because of severe abdominal pain of 5 d duration. A computed tomography scan showed an undefined liquid collection involving a linear image 35 mm in size, suggestive of a foreign body. On laparotomy, an abscess containing a fish bone was resected. As fish bone ingestion is usually not remembered by the patient, the diagnosis can be delayed. The preoperative diagnosis is frequently acute abdomen of unknown cause. A low threshold of suspicion along with a good clinical history and radiological studies are extremely important in order to make a correct diagnosis.     

Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions

STUDY OBJECTIVE: We sought to synthesize the literature on patterns of use of emergency services among older adults, risk factors associated with adverse health outcomes, and effectiveness of intervention strategies targeting this population. METHODS: Relevant articles were identified by means of an English-language search of MEDLINE, HealthSTAR, CINAHL, Current Contents, and Cochrane Library databases from January 1985 to January 2001. This search was supplemented with literature from reference sections of the retrieved publications. A qualitative approach was used to synthesize the literature. RESULTS: Compared with younger persons, older adults use emergency services at a higher rate, their visits have a greater level of urgency, they have longer stays in the emergency department, they are more likely to be admitted or to have repeat ED visits, and they experience higher rates of adverse health outcomes after discharge. The risk factors commonly associated with the negative outcomes are age, functional impairment, recent hospitalization or ED use, living alone, and lack of social support. Comprehensive geriatric screening and coordinated discharge planning initiatives designed to improve clinical outcomes in older emergency patients have provided inconclusive results. CONCLUSION: Older ED patients have distinct patterns of service use and care needs. The current disease-oriented and episodic models of emergency care do not adequately respond to the complex care needs of frail older patients. More research is needed to determine the effectiveness of screening and intervention strategies targeting at-risk older ED patients.     

Blood pressure in firefighters, police officers, and other emergency responders

Elevated blood pressure is a major risk factor for cardiovascular morbidity and mortality. Increased risk begins in the prehypertensive range and increases further with higher pressures. The strenuous duties of emergency responders (firefighters, police officers, and emergency medical services (EMS) personnel) can interact with their personal risk profiles, including elevated blood pressure, to precipitate acute cardiovascular events. Approximately three-quarters of emergency responders have prehypertension or hypertension, a proportion which is expected to increase, based on the obesity epidemic. Elevated blood pressure is also inadequately controlled in these professionals and strongly linked to cardiovascular disease morbidity and mortality. Notably, the majority of incident cardiovascular disease events occur in responders who are initially prehypertensive or only mildly hypertensive and whose average premorbid blood pressures are in the range in which many physicians would hesitate to prescribe medications (140-146/88-92). Laws mandating public benefits for emergency responders with cardiovascular disease provide an additional rationale for aggressively controlling their blood pressure. This review provides a background on emergency responders, summarizes occupational risk factors for hypertension and the metabolic syndrome, their prevalence of elevated blood pressure, and evidence linking hypertension with adverse outcomes in these professions. Next, discrepancies between relatively outdated medical standards for emergency responders and current, evidence-based guidelines for blood pressure management in the general public are highlighted. Finally, a workplace-oriented approach for blood pressure control among emergency responders is proposed, based on the seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.     

Emergency psychopharmacology: a review and update

The emergency area is a difficult site for the practice of careful psychopharmacology. The detailed history taking and collaborative treatment relationship often found in the consultant's office is rarely present. Instead, rapid decisions are made under a variety of pressures, with patients who may be uncooperative and unwilling to be treated. Many emergency patients are concurrently in treatment with a psychotherapist or psychopharmacologist who is available for consultation to the emergency service. When this is possible it is of great potential value, both in arriving more quickly at an appropriate treatment and in preventing a harmful opposition of the patient's treatment resources. For patients who are not currently in another treatment, additional helpful information often may be obtained from friends or family members. This is especially useful in treating patients who are acutely psychotic, unable to communicate, or uncooperative with the emergency interview. Although psychopharmacological approaches properly chosen often yield rapid results, medications are only a part of most emergency treatment plans. Medications are ineffective in a variety of crises and cannot replace careful interviewing of patients and others aimed at understanding the exogenous stress, change in interpersonal relationships, intrapsychic conflict, or biological disorder that precipitated an emergency visit. Furthermore, the decision to treat with medications must include a consideration of the adverse effects that may occur. With these limitations in mind, the area of emergency psychopharmacology can provide powerful assistance to emergency clinicians.     

Circadian rhythm, shift work, and emergency medicine

Human beings, like other living organisms, have physiologic systems that are cyclic in nature. Many of these systems have a circadian length. This provides for internal stability while at the same time enabling the organism to interact with the external environment and respond to changes in that environment. These physiologic systems, including those with a circadian length, can change timing as a result of environmental cues, such as the light-dark cycle or seasonal variations, but this takes time. When people engage in rotating or night shift work, the circadian rhythms are unable to quickly adapt to a rapidly changing activity schedule. This results in desynchronosis of many physiologic systems, including those with circadian timing. Because many emergency physicians engage in shift work, they are subject to the effects of circadian rhythm disruption. Research on the effect of desynchronosis on emergency physicians is sparse but has demonstrated negative effects. This article reviews the effect of desynchronosis on the health and productivity of physicians engaged in shift work.     

Acute abdominal pain and eosinophilia, two cases of eosinophilic gastroenteritis.

Two patients are presented who were admitted with acute abdominal pain for which they underwent laparotomy. No clear-cut diagnosis could be established during operation. Eventually, eosinophilic gastroenteritis was diagnosed and treated with corticosteroids. The heterogeneous presentation of eosinophilic gastroenteritis is discussed, ranging from mild non-specific gastrointestinal symptoms to an acute abdominal emergency prompting surgical intervention. The pathogenesis and treatment of eosinophilic gastroenteritis are discussed.     

The mortality of untreated pulmonary embolism in emergency department patients

Much of the literature on pulmonary embolism that is commonly referenced by emergency physicians begins with statistics concerning how often the diagnosis is missed and the lethality of pulmonary embolism if undiagnosed and untreated. It is likely that many emergency physicians continue to pursue an aggressive diagnostic strategy even in low-risk patients because of concerns about the potential for poor patient outcome and the medicolegal consequences of a missed diagnosis. The believed and often-quoted mortality and recurrence rates for untreated or missed pulmonary embolism are 26% to 30%. However, these figures originate from investigations that have little relevance to modern emergency medicine, which include studies dating to the 1940s, many of which have significant methodologic pitfalls. These data are also based primarily on either inpatient or autopsy populations, neither of which is representative of patients treated in the emergency department (ED). Analysis of untreated or missed pulmonary embolism in ambulatory patients reveals mortality and recurrence rates of less than 5%. This article discusses the background of commonly quoted pulmonary embolism statistics and highlights the need for future investigations enrolling ED patients that focus on disease outcome in this population.     

Emergency Measurement of Stat, Timed, Serum Ethanol Levels for Medical Management

Because of a general impression that a substantial proportion of emergency medical problems requiring treatment or hospitalization was caused by unsuspected alcohol consumption, a study to question that impression was done on a population of urban emergency service patients. We evaluated blood samples taken from these patients for routine determinations for many reasons other than suspicion of alcohol use or abuse. Abnormalities in results of serum ethanol concentrations were found more frequently than abnormalities of concurrently determined serum electrolytes, urea nitrogen, or glucose. The frequency of abnormalities found was ethanol, 42%; carbon dioxide, 35%; glucose, 34%; chloride, 32%, sodium, 21%; potassium, 20%; and urea nitrogen, 13%. The high incidence of serum ethanol elevations in such hospital emergency service patients and the considerable potential usefulness of ethanol levels in diagnosis and management of a wide variety of medical problems suggest that determinations of stat, timed, serum ethanol concentrations are often indicated as an emergency study for urban populations.     

Clinical features in the management of selected hypertensive emergencies

A hypertensive emergency is a clinical diagnosis that is appropriate when marked hypertension is associated with acute target-organ damage; in this setting, lowering of blood pressure (BP) is typically begun within hours of diagnosis. For hypertensive urgency with no acute target-organ damage, BP lowering may occur over hours to days. A hypertensive emergency may present with cardiac, renal, neurologic, hemorrhagic, or obstetric manifestations, but prompt recognition of the condition and institution of rapidly acting parenteral therapy to lower BP (typically in an intensive care unit) are widely recommended. For aortic dissection, the systolic BP target is lower than 120 mm Hg, to be achieved during the first 20 minutes using a beta-blocker (typically esmolol) and a vasodilator to reduce both shear stress on the aortic tear and the BP, respectively. Otherwise, sodium nitroprusside is the agent with the lowest acquisition cost and longest record of successful use in hypertensive emergencies; however, it is metabolized to toxic thiocyanate and cyanide. Other attractive agents include fenoldopam mesylate, nicardipine, and labetalol; in pregnant women, magnesium and nifedipine are used commonly. Most authors suggest a reduction in mean arterial pressure of approximately 10% during the first hour and a further 10% to 15% during the next 2 to 4 hours; hypoperfusion can result if the BP is lowered too suddenly or too far (eg, into the range of <140/90 mm Hg). Oral antihypertensive therapy can usually be instituted after 6 to 12 hours of parenteral therapy, and the patient moved out of the intensive care unit, when consideration should be given to screening for secondary causes of hypertension. Long-term follow-up to ensure adequate control of hypertension is necessary to prevent further target-organ damage and recurrence of another hypertensive emergency.     

Emergency department ultrasound scanning for abdominal aortic aneurysm: accessible, accurate, and advantageous

STUDY OBJECTIVE: This study was conducted to determine whether emergency physicians with relatively limited training and experience can accurately identify the presence or absence of abdominal aortic aneurysms (AAAs) by performing bedside ultrasound scanning, and to assess the potential impact of ultrasound scanning on clinical management. METHODS: Patients in whom AAAs were suspected, including those patients older than 50 years presenting with abdominal/back pain of unclear origin or presumed renal colic, were eligible for study entry. Consenting adults had ultrasound scanning by an emergency physician who was not responsible for their primary care. Treating physicians remained blinded to the results unless an unexpected AAAs was discovered. Scan accuracy was ascertained by comparing our ultrasound results with preselected gold standards. The clinical impact of the ultrasound studies was determined by comparing the preultrasound and postultrasound assessment sheets that detailed the presumed diagnosis, proposed investigations and therapies, and patient disposition. RESULTS: Our convenience sample includes 68 scans for AAAs; findings of 26 scans were positive, 40 scans yielded negative findings, and 2 scans were indeterminate. Scan interpretations were 100% accurate. The ultrasound results would have improved the care of 46 patients without adverse sequelae. Ultrasound scanning served primarily to exclude AAA in patients who proved not to have aneurysms; however, scans also provided significant benefits for those with AAAs and improved patient management plans. CONCLUSION: Relative neophytes can perform aortic ultrasound scans accurately. These scans appear useful as a screening measure in high-risk emergency department patients; they may also aid in rapidly verifying the diagnosis in patients who require immediate surgical intervention.