Acute hyperlipidemic pancreatitis in a pregnant woman

BACKGROUND:

Acute pancreatitis is a serious complication during pregnancy, however the incidence of hyperlipidemia induced by pancreatitis is lower.

METHODS:

We treated a pregnant woman with hypertriglyceridemia-associated acute gestational pancreatitis who simultaneously developed hypoxemic acute respiratory failure (ARF).

RESULTS:

The woman was successfully treated through noninvasive positive pressure ventilation (NPPV), emergent caesarean delivery, drainage of chylous ascites, and peritoneal lavage.

CONCLUSION:

The signs and symptoms of ARF were greatly improved in this patient after NPPV and conventional therapies. Early NPPV may be related to good prognosis of the disease.KEY WORDS: Hyperlipidemia, Pancreatitis, Pregnancy     

A potentially life-threatening complication of university orientation activities

BACKGROUND:

This case report describes a university student who participated in an orientation activity and developed exertional rhabdomyolysis.

METHODS:

With prompt intravenous volume expansion started in the accident and emergency department, he made an uneventful recovery despite a marked elevation of creatine kinase. The riskfactors of developing exertional rhabdomyolysis were reviewed. Suggestions based on these risk factors were made to the organizers of such orientation programmes.

RESULTS:

He was discharged on day 6. On follow-up on day 8 after presentation at theaccident and emergency department, the CK level was 46 000 U/L and it fell to 2600 U/L in another 2 weeks. On follow-up 3 weeks after the incident, he remained well without symptoms.

CONCLUSION:

For the clinicians, once rhadbomyolysis is suspected or diagnosed, intravenous fluid therapy with a crystalloid should be initiated as soon as possible to prevent the occurrence of acute renal faiure.KEY WORDS: Rhadbomyolysis, Acute renal faiure     

Bilateral stones as a cause of acute renal failure in the emergency department

BACKGROUND:

Acute renal failure (ARF) due to obstructive uropathy is a urological emergency. The standard radiological investigations in the emergency setting include X-ray, ultrasonography and computed tomography. But occasionally the cause of obstruction may be elusive.

METHODS:

We present a case of obstructive uropathy due to bilateral stones presenting as acute renal failure. The patient underwent successful shock wave lithotripsy (SWL) for dissolution of calculi.

RESULTS:

The patient was successfully treated, and reported asymptomatic in a follow-up.

CONCLUSION:

Close collaboration between nephrological, urological, and radiological services is required.KEYWORDS: Bilateral stones, Acute renal failure, Obstructive uropathy     

Oral acyclovir induced acute renal failure

BACKGROUND:

The study aimed to investigate the clinical characteristics of acute renal failure (ARF) caused by oral acyclovir.

METHODS:

A 45-year-old Chinese male patient with acyclovir-induced ARF suffered from abdominal pain for one day. The pain was extended to the epigastric area from the right lower quadrant. Transient oliguria was seen in addition to microscopic hematuria and proteinuria. The serum creatinine concentration was 304 μmol/L. Eight days before the occurrence of ARF, the patient took oral acyclovir for facial neuritis.

RESULTS:

His renal function was restored completely following the discontinuation of acyclovir, with continuous renal replacement therapy for 54 hours and some symptomatic treatment.

CONCLUSION:

The presentation of acute renal failure caused by acyclovir can be diverse, but the prognosis is good after active treatment.KEY WORDS: Acute renal failure, Acyclovir, oral, Continuous vein-vein hemofiltration     

Artificial liver support system in treatment of liver failure after acute poisoning

BACKGROUND:

Acute poisoning (AP) may cause failure of the liver and kidney, and even death. This study aimed to investigate the efficacy of artificial liver support system (ALSS) on the treatment of liver failure after acute poisoning.

METHODS:

A total of 31 patients with liver failure caused by AP were admitted to emergency ICU, central ICU, and Department of Gastroenterology from 2005 to 2009 in Zhongshan Hospital Affiliated to Xiamen University, China. Among them, 13 patients served as a treatment group, and used ALSS in addition to detoxification treatment and protective treatment of liver function, and the other 18 patients served as a control group receiving detoxification treatment and protective treatment of liver function.

RESULTS:

In the treatment group, 10 patients (76.9%) were cured or improved, 2 died, and 1 was discharged against advice. In the 18 patients in the control group, 7 (38.9%) were cured or improved, 3 died, and 8 were discharged against advice. There was a significant difference in the rates of improvement between the two groups (P<0.05).

CONCLUSION:

ALSS is a safe and effective clinical method for the treatment of acute toxic liver failure.KEY WORDS: Toxicity, Liver failure, Artificial liver support system     

No Association between Hyponatremia and Rhabdomyolysis in Rats

Background

Rhabdomyolysis is an uncommon complication of hyponatremia, reported previously only in case reports and small retrospective studies, and its underlying mechanism is controversial. Some studies support the hypothesis that the rapid correction of hyponatremia is responsible for rhabdomyolysis, whereas others emphasize the severity of the hyponatremia as a predisposing factor for rhabdomyolysis.

Objectives

To test the association between hyponatremia and rhabdomyolysis and to demonstrate a causal association.

Methods

Hyponatremia was induced by administration of water and desmopressin acetate in rats during 3 days, followed by its rapid correction, using animal models established for the evaluation of central pontine myelinolysis. The plasma creatine phosphokinase levels, a marker for rhabdomyolysis, were monitored, and hematoxylin and eosin sections of the quadriceps and gastrocnemius muscles were evaluated for signs of rhabdomyolysis.

Results

The induction of hyponatremia and its correction were accompanied by the previously reported neurological sequelae, including signs of central pontine myelinolysis. However, no increase in plasma creatine phosphokinase levels was found, and histopathological examination of the quadriceps and gastrocnemius muscles revealed no sign of rhabdomyolysis.

Conclusions

The present study, which is the first to test the association between hyponatremia and rhabdomyolysis in an animal model, does not support any causal association between hyponatremia and rhabdomyolysis. Thus, other factors might be necessary for an association between hyponatremia and rhabdomyolysis, such as genetic factors or convulsions that are known to be associated with both hyponatremia and rhabdomyolysis. Further research in this important physiologic and clinical question is needed.     

Acute ischemic stroke in a child with cyanotic congenital heart disease due to non-compliance of anticoagulation

BACKGROUND:

Stroke is a common presentation in geriatric patients in emergency department but rarely seen in pediatric patients. In case of acute ischemic stroke in pediatric age group, management is different from that of adult ischemic stroke where thrombolysis is a good op.

METHODS:

We report a case of a 17-year-old male child presenting in emergency with an episode of acute ischemic stroke causing left hemiparesis with left facial weakness and asymmetry. The patient suffered from cyanotic congenital heart disease for which he had undergone Fontan operation previously. He had a history of missing his daily dose of warfarin for last 3 days prior to the stroke.

RESULTS:

The patient recovered from acute ischemic stroke without being thrombolyzed.

CONCLUSION:

In pediatric patients, acute ischemic stroke usually is evolving and may not require thrombolysis.KEY WORDS: Acute ischemic stroke, Congenital heart disease, Single ventricle, Fontan operation, Warfarin, Thrombolytic     

An evidence-based narrative review of the emergency department evaluation and management of rhabdomyolysis

Background

Rhabdomyolysis is a medical condition caused by muscle breakdown leading to potential renal damage. This can result in significant morbidity and mortality if not rapidly identified and treated.

Suicidal ingestion of potassium permanganate

BACKGROUND:

Potassium permanganate is used clinically as an antiseptic and antifungal agent. Ingestion of potassium permanganate may result in damage to the upper gastrointestinal tract. Burns and ulceration of the mouth, esophagus and stomach occur due to its action. Emergency endoscopy is useful to assess the severity of damage and also to guide management.

METHODS:

We reported a patient presenting to the emergency department after suicidal ingestion of potassium permanganate.

RESULTS:

After treatment, the patient was discharged home on the 7th day after admission.

CONCLUSION:

Early emergency endoscopy should be considered to determine the extent of upper gastrointestinal damage in the emergency department.KEY WORDS: Emergency endoscopy, Gastric damage, Suicide, Potassium permanganate     

The Acinetobacter baumannii group: a systemic review

BACKGROUND:

The Acinetobacter baumannii group, including Acinetobacter baumannii, Acinetobacter genomospecies 3 and 13TU, is phenotypically indistinguishable and uniformly identified as Acinetobacter baumannii by laboratories of clinical microbiology. This review aimed to demonstrate the differences among them.

METHODS:

Literatures associated with the Acinetobacter baumannii group were identified and selected from PubMed databases and relevant journals.

RESULTS:

Acinetobacter genospecies 3 and 13TU possess a certain proportion in clinical isolates. There were considerable differences in epidemiologic features, clinical manifestations, antimicrobial resistances and therapeutic options among the Acinetobacter baumannii group. Compared with Acinetobacter genomospecies 3 and 13TU, Acinetobacter baumannii with a higher resistance to antimicrobial agents are easier to be treated inappropriately, and present a worse outcome in patients.

CONCLUSION:

The Acinetobacter baumannii group comprises three distinct clinical entities, and their clinical value are not equal.KEY WORDS: Acinetobacter baumannii, Acinetobacter genomospecies 3, Acinetobacter genomospecies 13TU, Difference     

Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department

BACKGROUND:

Abdominal wall hematoma is due to trauma, coagulation disorders or anticoagulation therapy complications.

METHODS:

In this report we present a case of a 44-year-old female who suffered from blunt abdominal trauma and presented to the emergency department with sharp abdominal pain and ecchymosis. FAST and abdominal computerized tomography (CT) revealed an abdominal wall hematoma. Treatment with an ultrasound-guided percutaneous drainage was performed successfully.

RESULTS:

The patient remained under observation for six hours with serial ultrasound scans, and no signs of hematoma recurrence were present. She was discharged the same day with clinical improvement.

CONCLUSION:

Complete history investigation and clinical examination help to make a correct diagnosis of abdominal wall hematoma, select a prompt treatment, and reduce complications.KEY WORDS: Rectus sheath hematoma, Abdominal wall hematoma, Emergency Department, FAST, Ultrasound guided percutaneous drainage     

Rhabdomyolysis in a patient complicated with hypopituitarism and multiple organ dysfunction syndrome and the literature review

Introduction

Muscular symptoms, including stiffness, myalgia, cramps, and fatigue, are present in the majority of the patients with hypopituitarism, adrenal insufficiency and hypothyroidism, but rhabdomyolysis, the rapid breakdown of skeletal muscle, is a rare manifestation. In most patients who develop rhabdomyolysis, precipitating factors, such as strenuous exercise or use of lipid-lowering drugs, can be identified.

Images in emergency medicine: giant ascending aortic aneurysm dissection with hemopericardium

BACKGROUND:

Acute chest pain represents a common presentation at emergency department. Aortic dissection in young patients, however, is fortunately rare.

METHODS:

We report a case of giant ascending aortic aneurysm with Stanford type A aortic dissection in an otherwise well 22-year-old male patient. Operative aortic valve and root replacement was undertaken with favourable outcome.

RESULTS:

Histopathologic examination of the resected aorta revealed acute on chronic inflammatory change with Langerhans type giant cells consistent with a diagnosis of giant cell aortitis.

CONCLUSION:

While uncommon, emergencies of the aorta may present in young patients. Predisposing conditions are discussed.KEY WORDS: Aorta, Aneurysm, Tamponade, Dissection     

Traumatic lumbar hernia

BACKGROUND:

Trauma has various presentations ranging from common injuries that are easily managed to uncommon presentations such as traumatic hernia that may be missed.

METHODS:

Despite being operated for fracture of the femur after a road traffic accident, a 50-year-old female patient remained undiagnosed with a right sided traumatic lumbar hernia for nearly six months after the accident. In this period, the patient underwent incision and drainage thrice for swelling in the right flank which was diagnosed as an infected hematoma by a doctor.

RESULTS:

The patient underwent surgery for repair of traumatic lumbar hernia by combined fascia lata graft and mesh hernioplasty. She remains well on follow-up.

CONCLUSION:

This case underscores the need for awareness of this entity for correct diagnosis and appropriate management that are the key to avoiding complications.KEY WORDS: Trauma, Femur, Hematoma, Hernioplasty, Fascia lata     

Cushing's reflex in a rare case of adult medulloblastoma

BACKGROUND:

Medulloblastoma is a primitive neuro-ectodermal tumor. It is common in childhood, but rarely seen at adult age, comprising only 1% of primary brain tumors.

METHODS:

We treated a 31-year-old man presented to the emergency department (ED) with a chief complaint of nausea and vomiting for one week duration. Immediate frozen section revealed a grade IV medulloblastoma. During the hospital course, the patient was given craniospinal irradiation with chemotherapy.

RESULTS:

The patient was eventually discharged from the hospital to an assisted living facility after an uneventful 15-day course with the aid of social work.

CONCLUSIONS:

Despite intracranial tumors generally being slow growing masses, this patient demonstrates how quickly one can decompensate, and how important it is to recognize these clinical signs and symptoms of an intracranial lesion. Although these symptoms (i.e. Cushing response) are extremely rare, the ED physician should be aware and appreciate their clinical significance.KEY WORDS: Medulloblastoma, Adualt, Cushing''s reflex     

Acute myocardial infarction in a child with myocardial bridge

BACKGROUND:

Myocardial infarction (MI) is rare in children, and Kawasaki disease is now recognized as the main cause for MI. In this report, we present a child with MI caused by myocardial bridge (MB).

METHODS:

A 7.5-year-old boy was admitted to Weifang People’s Hospital on September 16, 2008 for heart disease. By electrocardiogram, coronary CT angiography, emission computed tomography, and other examinations, he was initially diagnosed as having (1) acute inferior myocardial infarction and extensive anterior myocardial infarction; (2) fulminant myocarditis; or (3) coronary myocardial bridge. He was treated with oxygen, thrombolysis, myocardial nutrition, vitamin C (4.0 g per time), dexamethasone (7.5 mg per time), a large dose of gamma globulin, and interferon.

RESULTS:

Myocardial enzymes, liver function, C-reactive protein, and troponin-I returned to normal at 21 days after treatment. At 29 days, electrocardiogram indicated that II, III, aVF, V4 - V6 leads had abnormal Q wave, and ST-T changed. The patient was discharged.

CONCLUSION:

Myocardial bridge may be one of the causes of MI in children.KEY WORDS: Myocardial bridge, Electrocardiogram, Acute myocardial infarction     

Infective endocarditis complicated with cerebral and splenic infarction in a hemodialysis patient

BACKGROUND:

Infective endocarditis (IE) has a high risk of morbidity and mortality. Complications are often due to systemic embolization. We treated a 47-year-old hemodialysis man with infective endocarditis complicated with cerebral and splenic infarction.

METHODS:

The patient was brought to the emergency department because of altered mental status and fecal incontinence. Although he did not meet the Duke Criteria for IE diagnosis, clinical suspicions of IE warranted further diagnostic studies. Magnetic resonance imaging of the brain revealed cerebral infarction with abnormal neurological findings. An abdominal computerized tomography revealed an incidental and unexpected splenic infarction without physical findings. Echocardiography revealed a vegetative growth (−1.2×1 cm) over the mitral posterior leaflet with severe mitral valve regurgitation. Based on these results, the patient was diagnosed with IE complicated with severe cerebral and splenic infarction.

RESULTS:

The patient was treated with intravenous teicoplanin including gentamicin, subcutaneous low molecular weight heparin, and oral acetylsalicylic acid. Mitral valve replacement surgery was performed after the patient improved clinically.

CONCLUSION:

Emergency physicians should be aware of the life-threatening complications of IE, which may be presented subtly or without clinical evidence.KEY WORDS: Infective endocarditis, Cerebral infarction, Splenic infarction     

A continuous quality improvement project to reduce medication error in the emergency department

BACKGROUND:

Medication errors are a common source of adverse healthcare incidents particularly in the emergency department (ED) that has a number of factors that make it prone to medication errors. This project aims to reduce medication errors and improve the health and economic outcomes of clinical care in Hong Kong ED.

METHODS:

In 2009, a task group was formed to identify problems that potentially endanger medication safety and developed strategies to eliminate these problems.

RESULTS:

Responsible officers were assigned to look after seven error-prone areas. Strategies were proposed, discussed, endorsed and promulgated to eliminate the problems identified. A reduction of medication incidents (MI) from 16 to 6 was achieved before and after the improvement work.

CONCLUSION:

This project successfully established a concrete organizational structure to safeguard error-prone areas of medication safety in a sustainable manner.KEY WORDS: Medication error, Medication safety, Continuous Quality Improvement (CQI)     

Free tubercular perforation of the ileum

BACKGROUND:

Peritonitis secondary to small bowel perforation is a common surgical emergency seen across the globe.

METHODS:

A young male patient presented with ileal perforation that was repaired primarily. He recovered uneventfully after the operation.

RESULTS:

Histopathology of the margins of the perforation revealed tuberculosis. A search for evidence of a primary focus of tuberculosis was unsuccessful. The patient was started on anti- tubercular therapy and he was followed up with good results.

CONCLUSION:

This present case underscores the importance of biopsy specimens taken from the margins of patients with ileal perforation to avoid the misdiagnosis of such condition.KEY WORDS: Peritonitis, Perforation, Ileum, Tuberculosis