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Emergency casebook

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Vertebral artery dissection and cerebellar infarction following chiropractic manipulation ▸

Vertebral artery dissection (VAD) associated with chiropractic cervical manipulation is a rare but potentially disabling condition. In this report, we present a young patient manifesting with repeated vertigo. Due to the initial misdiagnosis, the patient later developed cerebellar stroke with inability to stand and walk. Vertigo and disequilibrium are usual presenting symptoms in emergency department (ED), which can result from inner ear or vestibular nerve dysfunction, vertebrobasilar insufficiency, and even lethal cerebellar infarction or hemorrhage. Although rarely seen in young adults, the last two due to traumatic or spontaneous arterial injury—including injury secondary to chiropractic cervical manipulation may occur. A number of cases about VAD associated with chiropractic cervical manipulation have been reported, but rarely in emergency medicine literature. In the case report, we discuss this rare occurrence, with emphasis on the diagnostic pitfalls in ED.

http://emjonline.com/cgi/content/full/23/1/e1. doi: 10.1136/emj.2004.015636

How ECG can cause confusion in pulmonary embolism and how echocardiogram can help ▸

Most deaths from pulmonary embolism (PE) occur because of a delay in diagnosis. ECG changes suggesting cardiac ischaemia can cause confusion but is well recognised in massive PE. In these cases early echocardiogram is important especially in the presence of hypotension/collapse. The case highlights the value of an early use of echocardiogram in the diagnosis of acute massive PE.

Most ECG features in PE lack specificity and sensitivity and the value of ECG for the diagnosis of PE is debatable. Once the diagnosis of PE has been established, the ECG could allow the massive forms to be distinguished. Echocardiography can be helpful when a massive PE is suspected. Echocardiography can be diagnostic of massive PE. However, it should not be used as a screening tool for diagnosing PE as it allows a firm diagnosis in only a minority of cases of PE.

. http://emjonline.com/cgi/content/full/23/1/e2. doi: 10.1136/emj.2003.011197

Aluminium phosphide poisoning ▸

We describe a lethal poisoning in a healthy woman caused by deliberate ingestion of aluminium phosphide (AlP), a pesticide used to kill rodents and insects. Toxicity of AlP and review of cases reported to the National Poisons Information Service (London) 1997-2003 are discussed.

http://emjonline.com/cgi/content/full/23/1/e3. doi: 10.1136/emj.2004.015947

Factitious buccal lesion secondary to bruxism in a child with cerebral palsy ▸

We present a case of a young girl with cerebral palsy who presented with an enlarging and obviously painful lesion on her buccal mucosa that had failed to resolve despite repeated courses of both antibiotic and antiviral medication.

After a period spent observing the girl’s non-verbal methods of communication it became apparent that she exhibited marked bruxism (tooth grinding) and that the lesion was infact self inflicted as she used the tooth grinding in order to gain her mothers attention at times of distress and hunger.

Through drawing her mother’s attention to the problem and over time as the girl’s verbal communication skills improved the lesion resolved as her bruxism receded.

We review both the typical and less common types of factitious lesion that present in children with various forms of learning difficulty and discuss the underlying causes and best methods of treatment for what is often a difficult to diagnose problem.

http://emjonline.com/cgi/content/full/23/1/e4. doi: 10.1136/emj.2004.020073

Is the patient brain-dead? ▸

Snake bite is a common medical emergency in the tropics. Among the snake bites the major fatality is due to neurotoxic snake envenoming. In this report we describe a patient with severe (patient requiring mechanical ventilation) neurotoxic snake bite who presented with neuromuscular respiratory failure and absent brain-stem reflexes, and at one instance was even thought to be brain dead. Although the history of snakebite was not forthcoming, the patient was managed empirically with snake anti-venom and supportive care in the form of mechanical ventilation, deep venous thrombosis, stress ulcer prophylaxis, and care of the comatose patient. The patient made a complete recovery and was discharged with no neurological sequelae.

We summarise the neurotoxic manifestations and pathophysiological basis of Elapid snake bite and review the current management. We also describe the potential pitfalls of diagnosing brain death in a patient with neuromuscular paralysis and ‘locked-in’ state and corrective measures to prevent this fatal error. In conclusion we stress that patients with unexplained neuroparalytic syndrome in areas where snake bites are endemic, even in the absence of history of snake bite, should attract the attention of the emergency room physicians of the possibility of Elapid snake bite. Early and energetic therapy even in the most severe cases is associated with excellent outcomes.

http://emjonline.com/cgi/content/full/23/1/e5. doi: 10.1136/emj.2004.019182

Noninvasive ventilation in acute neuromuscular respiratory failure due to myasthenic crisis: case report and review of literature ▸

Myasthenic crisis is currently defined as an exacerbation of myasthenic weakness causing respiratory failure requiring intubation and mechanical ventilation. Noninvasive ventilation (NIV) refers to the provision of ventilatory support to the lungs without the use of an endotracheal airway. It has emerged as an important tool in the treatment of acute respiratory failure. It not only reduces the need for invasive mechanical ventilation and its associated complications, but can also reduce the complications associated with stay in the intensive care unit, the length of hospital stay and mortality in selected patients. Long-term use of NIV is recommended for patients with chronic neuromuscular respiratory failure and is in fact considered the treatment of choice; however there is no consensus for its use in acute neuromuscular failure.

In this report we describe a patient of myasthenia gravis who presented with acute neuromuscular respiratory failure and was successfully managed with intravenous immunoglobulin and bilevel positive airway pressure. We also review the current literature on the role of NIV in acute neuromuscular respiratory failure. We also suggest a new definition for myasthenic crisis “as an exacerbation of myasthenic weakness causing respiratory failure”, because not all patients will require mechanical ventilation.

Finally, the decision to use NIV in acute neuromuscular failure depends upon the severity of the ventilatory failure, the presence or absence of bulbar involvement, and the availability of other effective treatments—for example, in myasthenia gravis and Guillain-Barré syndrome. However repeated clinical assessment and frequent arterial blood gas measurements are required in the first 6-8 hours to allow the physician to judge the efficacy of NIV and the need for invasive ventilation.

http://emjonline.com/cgi/content/full/23/1/e6. doi: 10.1136/emj.2004.019190

Hypopharyngeal perforation following minor trauma: a case report and literature review ▸

A rare complication of non-penetrating blunt neck trauma, hypopharyngeal perforation is mainly reported in association with high velocity road traffic accidents. The proposed injury mechanism is neck hyperextension associated with airway closure due to cervical compression against the steering wheel. Low velocity direct blows to the neck have also been associated with pharyngeal perforation. We report a case of hypopharyngeal perforation following a low velocity motorcycle accident where neither mechanism of injury was apparent. The presumed mechanism of injury in this case was cervical spine hyperextension without cervical compression.

http://emjonline.com/cgi/content/full/23/1/e7. doi: 10.1136/emj.2003.012187

Two cases of retroperitoneal haematoma caused by interaction between antibiotics and warfarin ▸

A number of commonly prescribed antibiotics are known to interact with warfarin, increasing its anticoagulant effect by different mechanisms. Retroperitoneal bleeding and consequent haematoma is well recognised as a complication of over-anticoagulation. Consequences, which are potentially fatal, include hypovolaemic shock and compression of retroperitoneal structures such as the ureter and inferior vena cava (IVC). We present two such cases and a discussion of the issues, which are raised. The first patient was being anticoagulated as treatment for pulmonary embolus. Antibiotics including trimethoprim and metronidazole were used to treat a urinary tract infection. The second patient was prescribed warfarin after suffering transient ischaemic attacks and being diagnosed with paroxysmal atrial fibrillation. A lower respiratory tract infection was treated with a macrolide antibiotic. In both cases the effect of warfarin was potentiated and the patients suffered bleeding complications.

http://emjonline.com/cgi/content/full/23/1/e8. doi: 10.1136/emj.2004.016345

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