Clinical Case | Life in the Fast Lane

ED Thoracotomy: Is it Just the First Part of the Autopsy?

August 19, 2010 By Kane Guthrie View Comments

Thoracic trauma is one of the leading causes of death in all age groups and accounts for 25-50% of all traumatic injuries. The majority of thoracic trauma patients require conservative management only, however a subset of these patient will deteriorate in the pre-hospital environment or in the emergency department requiring an emergency thoracotomy to allow the heart to keep contracting and perfusing vital organs.

Filed Under: Clinical Case, Education, Emergency Medicine, Featured, Health, Trauma Tagged With: Blunt Trauma, chest trauma, Emergency Department Thoracotomy, Emergency Resuscitative Thoracotomy, Penetrating Trauma

Purchase Nexium

July 21, 2010 By Chris Nickson View Comments

Over the last year new LitFL posts have been dominated by things we call 'Case-based Q&As Purchase Nexium, ' --- you may wondering whats going on.

Don't worry, Nexium free sample, LitFL is going to stay true to its quirky and eccentric medical blogging roots...

Updates and interpretation of the latest in Web 2.0/3.0/4.0... and social medicine, help paying for nexium,

UCEM will continue its quest for world domination/ salvation, Can nexium relieve the heatburn symptoms,

The odd philosophical aside will still spring up,

Poetical bastardisation will march onwards,

Neologisms will be created, nexium protonix,

Whimsical human encounters will be de-identified, Online nexium, further fictionalised and shared,

...and the case-based Q&As are going to keep on cranking too.

Personally, I like to learn by a problem-based approach using the Socratic Method (or positive pimping if you prefer), nexium on the internet, where an experienced learner/ teacher helps others through guided questioning and explanation. Generic nexium buy online, The Case-based Q&As are an attempt to extract the precious bodily fluids from this approach and distill them into an open-source and easily retrieved bottle of port (i.e. something that tastes good and is easy to swallow).., Purchase Nexium. The emphasis on cases, though tenuous and borderline farcical at times, nexium actor, attempts to keep it real, Nexium 90 day coupon, relevant, interactive and interesting.

The question/answer show/hide format makes for easy revision, appropriate usage for nexium, provides an easily comprehensible structure and allows readers to come back, Nexium medicare plan d, revise and test their knowledge. Questions and answers can be easily cut-and-pasted into personal notes, edited and modified, over counter nexium, or turned into flashcards for using spaced-repetition programs like Mnemosyne for those so inclined. Prevacid nexium reflux, Many of the answers are in two stages --- a brief to-the-point bare bones answer, followed by a deeper explanation. Purchase Nexium, In general, the focus is on what the clinician needs to know to take care of their patient and pass their exams --- thus extraneous epidemiology and molecular underpinnings tend to be limited. Of course, nexium generic esomeprazole trihydrate, we have an unabashed predilection for breaking our own rules... Nexium for lprd,

The Case-based Q&As are ever growing, and the index is intermittently updated in a searchable table on the Clinical Cases page. The cases vary from core emergency medicine and critical care subjects that practitioners need to know like the backs of their hands, nexium 40 mg 60, to more obscure and 'out there' topics --- but why not. Compare omeprazole to nexium, We see it all in this business.

The best case-based Q&As are those like Paul Young's Pulmonary Puzzle 002 - Not just a PE; as the case evolves an incredible amount of diverse medical terrain is traversed, but the questions focus on the key messages and important learning points, Purchase Nexium.

Many cases, like Laboratory Tester 003 - Seizures, nexium prescriptions, hyponatremia and ADH, Nexium time release, evolve from our own learning needs and differences of opinion at work, the clinical questions that arise as we try to do what is best for our patients and the controversies we encounter.

Other cases, trying to wean off nexium, like Trauma Tribulation 005 - Releasing the Roman Breastplate, Compare prices nexium, are more conventional and designed to cover core knowledge requirements. Where possible the posts are referenced, usually with at least one of the ACEM or CICM Fellowship exam recommended texts (typically Rosen's or Oh's, is nexium addictive, respectively), Imitrex nexium, unearthed gems from the primary literature and recent review articles, and/or the best online and open-source resources we can find on the web.

Oh, nexium physical properties, you have another question do you --- what's with the naming of the posts.

Purchase Nexium, Well, we've finally settled on a system of giving each post a category name, like 'Neurological Mind-boggler', and most posts will have another more post-specific name to keep things interesting. Buy generic nexium, Some readers get upset when post titles give away the diagnosis and others are irritated by the formulaic category names.

The current system promises to annoy both parties in equal measure... ;-)

Finally, what's the ultimate goal of all these 'Case-based Q&As' I hear you ask.

Well, the master plan is to build up an entire case-based curriculum for emergency medicine and intensive care catering for all levels of training. A 'big ask' I know, but hopefully in a few years we'll be able to say, "Well, we knocked the bastard off", just like New Zealand's most famous bee-keeper once did. But, we're not kidding ourselves --- we know this is a task that will never end, Purchase Nexium. I'd be disappointed if it did.

And now a postscript, a request. If you use these Case-based Q&A's fire some feedback our way (even better if its constructive!). We want these resources to be useful and as good as anything out there --- open-source or otherwise. If you want to submit a guest Case-based Q&A post having done some research on a relevant EM/ICU topic we will be happy to consider it if its quality stuff (contact the team here), and we'll credit you as the author. For instance, you might want to create a revision aid for a teaching talk you're going to give. Feel free to copy, re-use, modify and improve anything on LitFL for your own learning and teaching needs and do Hippocrates proud.

"To hold him who has taught me this art as equal to my parents and to live my life in partnership with him, and if he is in need of money to give him a share of mine, and to regard his offspring as equal to my brothers in male lineage and to teach them this art --- if they desire to learn it --- without fee and covenant; to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken the oath according to medical law, but to no one else."
--- from the Hippocratic Oath

Of course, if you learn something from these cases you may hear a knock on your door if we ever find ourselves totally skint... and feel free to ignore the 'no one else' part.

Filed Under: Blog News, Clinical Case, Clinical Interpretation, Emergency Medicine, Featured, Intensive Care, eLearning Tagged With: case-based Q&A, cases, critical care, eLearning, Emergency Medicine, Open-Source, problem-based learing, socratic method

Nexium Over The Counter

July 21, 2010 By Paul Young View Comments

aka Ob/Gyn Obsfuscation 001 Nexium Over The Counter, A 32 year-old woman is referred to the ICU post caesarean section. Child stool test positive nexium, She had an uneventful elective caesarian section 10 hours previously. She has been referred because in the last 2 hours she has developed vaginal bleeding and oozing from her epidural site, duration nexium usage. Nexium esomeprazole magnesium buy, Her vital signs are unremarkable except for a small oxygen requirement.

The following coagulation results are obtained:

Questions

Q1, nexium failure. Describe the results.

[DDET Answer and interpretation]

The INR is high, the APPT is high and the fibrinogen is very low, Nexium Over The Counter. Nexium purchase,

These results are consistent with disseminated intravascular coagulation (DIC).

[/DDET]

Q2. What abnormality would you expect to see on a blood film?

[DDET Answer and interpretation]

In severe DIC there are fragmented red blood cells (schistocytes), nexium patient advisory leaflet. Nexium strong urine smell, [/DDET]

Q3. What is the differential diagnosis?

[DDET Answer and interpretation]

In this case, nexium tablets patient information leaflet, Rebate nexium, potential pregnancy-related causes of DIC include:

1. Nexium Over The Counter, amniotic fluid embolism
2. pre-eclampsia
3, duration of nexium usage. Nexium 40 mg extended release, HELLP syndrome
4. post-partum haemorrhage

The fact that bleeding did not occur at the time of the caesarian section suggests that the problem has developed subsequently making amniotic fluid embolism the most likely diagnosis, nexium vs protonix. Prilosec nexium adverse reations, Other pregnancy-related causes of DIC (not relevant here) include:

1. placental abruption
2, Nexium Over The Counter. septic abortion
3, nexium health issues. Nexium peripheral neuropathy, intrauterine death

The most important non-pregnancy related cause of DIC that needs to be considered in this scenario is:

1. severe sepsis

[/DDET]

Q4, nexium prilosec differences. Lawsuit nexium, How would you treat this coagulopathy?

[DDET Answer and interpretation]

It turns out that knowing one thing about the coagulation cascade is useful:

That one thing is that conversion of fibrinogen to fibrin is at the bottom of the cascade. Nexium Over The Counter, That means that if the fibrinogen is low, the patient will not form clot until they get cryoprecipitate.

Any patient with a coagulopathy who has a low fibrinogen should have their fibrinogen corrected as the first priority.

The usual dose of cryoprecipitate is one unit of cryoprecipiate per 30 kg of body weight, woman in nexium commercial. Is nexium better than protonix, In this case, the fibrinogen level is exceptionally low and administration of a greater dose than this would be appropriate, bijwerkingen nexium. Nexium rx, The patient should also receive fresh frozen plasma and may require platelets (depending on the platelet count).
[/DDET]

References

Bick RL, lung cancer nexium. Syndromes of disseminated intravascular coagulation in obstetrics, pregnancy, and gynecology, Nexium Over The Counter. Nexium breast tenderness, Objective criteria for diagnosis and management. Hematol Oncol Clin North Am. 2000 Oct;14(5):999-1044, manufacturer nexium. Doctor nexium 40 pepcid 20, PMID: 11005032

Disseminated intravascular coagulation. (2010, July 4). In Wikipedia, The Free Encyclopedia. Retrieved 23:43, July 20, 2010

Filed Under: Blood Results, Clinical Case, Health, Medical Specialty Tagged With: amniotic fluid embolism, bleeding, coagulopathy, DIC, disseminated intravascular coagulation, pregnancy complications

Purchase Retin

July 20, 2010 By Chris Nickson View Comments

Volitional saccadic pathway with a lesion in the right medial longitudinal fasciculus (MLF) that results in an internuclear ophthalmoparesis (INO) Volitional saccadic pathway with a lesion in the right MLF that results in an INO during an attempted saccade to the patient's left (from neurology.org).

aka Neurological Mind-boggler 008 Purchase Retin, An elderly Scottish lady presented to the emergency department following a fall. Renova retin a white head cure, Apart from a few minor scrapes she came through the ordeal relatively unscathed. However, retin a loreal microdermabrasion, Order retin a, examination of her ocular movements demonstrated an abnormal finding.

She was asked to look to her right:

[caption id="attachment_20255" align="aligncenter" width="500" caption="Click to enlarge"][/caption]

And to her left:

[caption id="attachment_20256" align="aligncenter" width="500" caption="Click to enlarge"][/caption]

Q1, retin a generic. Retin virginia, Describe the clinical finding.

[DDET Answer and interpretation]

When the patient was asked to look right, there was voluntary conjugate deviation of the eyes to the right, rioc retin a. However, when she was asked to look to the left, the left eye abducted but the right eye failed to adduct --- it did not move past the midline, Purchase Retin. Cheap retin a micro,

In addition, although not shown in these images, retin a gel, Purchasing retin a, horizontal nystagmus was noted in the left eye when the the patient was asked to look to her left.

[/DDET]

Q2. What is the name of this clinical finding?

[DDET Answer and interpretation]

Unilateral internuclear ophthalmoplegia (INO) affecting the right eye.

In INO, retin advanced guestbook 2.4.3, .05 retin a cost, when the patient's gaze is directed away from the side of the lesion, the ipsilateral (adducting) eye will not adduct and the contralateral (abducting) eye demonstrates horizontal nystagmus, retin a mirco. Affirm retin,

Surprisingly, pateints with INO do not usually complain of diplopia!

[/DDET]

Q3, propecia rogaine retin. Lustra retin a, Where is the anatomical lesion?

[DDET Answer and interpretation]

Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus (MLF).

[caption id="attachment_20776" align="aligncenter" width="500" caption="Volitional saccadic pathway with a lesion in the right medial longitudinal fasciculus (MLF) that results in an internuclear ophthalmoparesis (INO) Volitional saccadic pathway with a lesion in the right MLF that results in an INO during an attempted saccade to the patient's left (from neurology.org)."]

[/caption]

The MLF provides a connection between CN3 nucleus in the midbrain (and, therefore, retin a prescription, Over the counter retin a creams, the medial rectus) and the CN6 nucleus in the pons (abducens) on the opposite side and facilitates conjugate eye movements on lateral gaze. Purchase Retin, Abduction in either eye is normal, whereas adduction is impaired, resulting in dissociation of eye movements --- in other words the eyes move independently on lateral gaze. When each eye is tested independently by covering the other eye, face retin, Acid glycolic retin, medial rectus function is shown to still be present. Saccades may be slow before adduction is impaired, strengths of retin a micro. Retin a 0.05,

In this case, the lesion is affecting the MLF between the left CN6 nucleus and the right CN3 nucleus.

[/DDET]

Q4, stages of retin a. Hydroquinone retin a gel combo, What are the possible causes of this clinical finding?

[DDET Answer and interpretation]

Causes of internuclear ophthalmoplegia (INO) include:

Multiple sclerosis ---
likely cause in adulthood/middle age; often bilateral.

Vascular brainstem lesion ---
likely cause in the elderly or people with vascular risk factors; often unilateral.

Pontine glioma ---
more likely cause in children.

Inflammatory encephalitis affecting the brainstem (e.g. autoimmune, infective)

Myasthenia gravis (unusual)

Bilateral INO is nearly pathognomonic for multiple sclerosis, Purchase Retin.

[/DDET]

Q5, retin a rebates. Retin topical, What is a one-and-a-half syndrome?

[DDET Answer and interpretation]

The ‘one-and-a-half’ syndrome is an internuclear ophthalmoplegia combined with a conjugate gaze paralysis in the other direction. One eye fails to adduct on attempted lateral gaze ('the half') and the other eye neither adducts nor abducts ('the one'). The eye that can abduct may exhibit horizontal nystagmus when it does so. Purchase Retin, The responsible lesion is an extensive paramedian pontine lesion that involves the MLF and either the CN6 nucleus or the PPRF (parapontine reticular formation). If the INO affects the left eye, the lesion is on the right (same side as the eye with the complete conjugate gaze palsy).

The PPRF is the brainstem gaze center that controls horizontal gaze. It innerves the CN6 nucleus and receives projections from higher centers including the contralateral frontal eye fields. An ipsilateral gaze palsy results from a lesion in either the PPRF or the CN6 nucleus.

One-and-a-half syndrome usually occurs in conjunction with other brainstem symptoms and signs.

The causes of one-and-a-half syndrome include:

Brainstem infarction ---
most common cause in the elderly.

Multiple sclerosis ---
most common cause in young adults.

Trauma

Postoperatively after posterior fossa procedure

Basilar artery aneurysm or brainstem arteriovenous malformations

Myasthenia gravis –--
'pseudo one-and-a-half syndrome'

[/DDET]

References

Bhidayasiri R, Waters MF, Giza CC, Purchase Retin. Neurological differential diagnosis: a prioritized approach, Blackwell Publishing 2005.

Duong DK, Leo MM, Mitchell EL. Neuro-ophthalmology. Emerg Med Clin North Am. 2008 Feb;26(1):137-80, vii. PMID: 18249261.

Patten J. Neurological differential diagnosis (2nd edition), Springer-Verlag 1996.

Filed Under: Clinical Case, Emergency Medicine, Featured, Health, Neurology, eLearning Tagged With: eye movement, internuclear ophthalmoplegia, medial longitudinal fasciculus, multiple sclerosis, one-and-a-half syndrome, stroke

Where Can I Buy Valium

July 17, 2010 By Kane Guthrie View Comments

Where Can I Buy Valium, Nasal foreign bodies are a common and challenging presentation to manage in the emergency department. A recent online article in Emergency Medicine Journal has shown that the "kissing" technique is effective 50% of the time at removing the object from the nasal cavity. The following post looks at a practical approach to nasal foreign bodies, Klonopin to valium, and explores the use of the "kissing" technique further.

Case Study

Its 5pm on a Friday afternoon. You're about to finish working for the day in the minor injury unit when the nurse brings in one last patient. She's a disgruntled 3 year old girl with a complaint of green, offensive and malodorous discharge coming from her right nostril.

On inspection of the rightnasal cavity you visualise a silver bead sitting just out of reach, valium diazepam history. The child reluctantly 'agrees' to sit on her mum's lap for a cuddle, Where Can I Buy Valium. You then ask her mother to seal her mouth over the child's, whilst occluding the unaffected nostril. Buy generic valium no membership, The mother then rapidly exhales into the child's mouth, shooting the little bead out across the room, resulting in great amusement for the child and an ear full of snot for the mother. After a quick check of the other nostril, ways to get valium, the child is on her way home and you make it to the Friday after-work sundowner.

[caption id="" align="aligncenter" width="400" caption="Image from: http://momwithastethoscope.files.wordpress.com"][/caption]

Nasal Foreign Bodies

Nasal foreign bodies are a common complaint presenting to emergency departments, predominately affecting the paediatric population under 5 years of age.

Often the child will admit to putting something in their nose, Iv valium opiophile, or have been witnessed doing it. However sometimes this history can be obscured and the child may present with localised pain, purulent unilateral discharge, epistaxis, valium 5mg roc, a voice change (with a "nasal" character), or a foul body/ breath odor.

The most commonly encountered foreign bodies are, Street value of valium, beads, beans, peanuts, toy parts, cheap fast overnight valium, pebbles, paper wads, Valium no prescribtion, and eraser tips.

The two most concerning foreign bodies are button batteries and magnets as they have the ability to cause localised necrosis and septal perforation in a relatively short period of time.

Nasal foreign bodies are commonly located just anterior to the middle turbinate or below the inferior turbinate, and affect the right side twice as often as the left. This may be related to right -handed individuals favouring the right side of the body.

Where Can I Buy Valium, Nasal foreign bodies generally result in local inflammation, bleeding and purulent discharge.

Differential Diagnosis

Epistaxis

Sinusitis

Polyps

Tumor

Upper respiratory tract infection

Unilateral choanal atresia

Assessment of Nasal Foreign Bodies

Investigations and imaging may not be necessary of the foregin body is visualised. Otherwise lateral x-rays of the head/neck/chest amy be helpful to locate the foreign body.

Pre-removal

Nasal foreign bodies can generally be seen on direct visualisation, buy generic valium, with the assistance of a nasal or otoscope speculum.

Always apply personal protective equipment, as spraying of projectile body fluids often occurs during removal.

Topical application of lignocaine and adrenaline can aid in assessment and removal, Valium fast shipping, by relieving pain, and providing lubrication.

A head lamp or over head light will greatly assistant in examination.

Have suction ready during examination to help remove debris --- sometimes it can even help remove the foreign body.

Post-removal

Always attempt (child permitting) to visualise to nasal cavity post removal, to assess for complete removal and localised trauma.

Epistaxis can occur post removal. Click here for a guide to the management of epistaxis.

Objects can be aspirated sometimes during removal, order valium without precription, always assess the airway, breathing and circulation should this occur

Emergency Department Management

Direct Instrumentation

Manual removal can be attempted in a cooperative or sedated child if the object is easily visualised, Valium drug company, and able to be grasped.

Right-angled hook probes can be passed alongside and past larger objects, rotated and gradually drawn back, removing the object.

Forceps can be used (alligator or bayonet), and are useful for objects near the anterior nares.

Suction

The use of wall suction can assist in retracting the object from the nasal cavity.

The noise from the suction can scare young children, comatose valium. T oavoid this try using the tubing without the suction catheter to decrease the noise made.

Positive pressure

Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

A nasal positive-pressure technique has been described as follows, Where Can I Buy Valium. Fda approved us online pharmacy valium, Topical anaesthetic is applied to both nares, then a male-male oxygen adapter with tubing, using an oxygen flow rate of 10-15L/min, is the placed into the unaffected nostril, lexapro valium interaction. The pressure generated may force the object out. However, Roche 5 valium, good co-operation from the child or procedural sedation may be needed.

The kissing technique has been around since 1965 and recent studies have shown that the technique has a 50% success rate, doesn't cause increase distress to the child or require sedation. This also means clinicians spend 50% less time playing aaround with snot!!

The technique is performed by a parent by placing their mouth over the child's (giving a 'big kiss'), while they occlude the unaffected nostril, valium without pr. Where Can I Buy Valium, The parent then exhales into the child's mouth, generating positive pressure, similar to that of nose blowing.

Magnets

Metal objects (ball bearings, nose piercings, magnets) have been successfully removed in the past using strong house hold magnets.

The magnet is held 1cm away from the affected nostril and is used to guide the object out of the nasal cavity.

There limited reports of the success of this method documented in the literature.

Other

Another method involves the use of a cotton tip applicator with super glue or dermabond applied to the tip. the tip is then carefully placed against the foreign body for 20-30secs, then gently rotated and removed bringing the foreign body out with it. Cheap valium free shipping, For more on this see the Academic Life in Emergency Medicine post: Trick of the trade: Ear foreign body removal.

Depending on the size of the nasal cavity and location of foreign body, it may be possible to gently insert a small size foley catheter past the foreign body, before inserting 1-2ml of water into the balloon, and gently retracting the catheter to dislodge the foreign body.

Rarely objects will be located so posteriorly that all of the above techniques will be futile, valium weight loss, and these patients should be referred to ENT for removal in theatre.

Procedural Sedation

When the above measures fail to remove the foreign body, or the child is to combative to attempt, Valium made, its time to consider procedual sedation. Some of the tricks and traps of procedural sedation and the removal of foreign bodies are discussed in Anaesthetic Addler 001: Nasal foreign body, ketamine and laryngospasm.

Medico-legal Pitfalls

These include:

Failing to promptly remove button batteries or magnets from the nose to prevent necrosis and septal perforation.

Failing to consult ENT specialist when there is suspected or proven damage to the nasopharynx requires ongoing management.

Not looking for other foreign bodies in the other nostril, when one has been located.

Not considering nasal foreign body in the diagnosis, herbal substitute valium, when a child present with unilateral odor and discharge.

Reference

Cameron, P. Cheap priced valium, Jelinek, G. Everitt, I, Where Can I Buy Valium. Browne, G, abrupt discontinue valium. & Raftos, J. Buy valium on line, (2006). Textbook of Paediatric Emergency Medicine. Google Books Preview Where Can I Buy Valium,

Taylor, C. Acheson, J. Coats, T. (2010). Nasal foreign bodies in children: kissing it better. Emergency Medicine Journal. PMID:20581404

Fischer, J, Where Can I Buy Valium. & Tarabar, A. (2008). Foreign Bodies, Nose. emedicine

Koppuravuri, M. Where Can I Buy Valium, & Makeham, J. (2010). Parent's kiss to remove nasal foreign bodies in children. BestBETs

Navitsky, R. Beamsley, A. & McLaughlin, S, Where Can I Buy Valium. (2002). Nasal positive-pressure technique for nasal foreign body removal in children. American Journal of Emergency Medicine. 20(2), 103-104. PMID: 11880873

Filed Under: Clinical Case, Pediatrics Tagged With: Foreign Body Removal, Kissing Technique, Nasal Foreign Bodies, paediatrics

Ambien Buy

July 12, 2010 By Oliver Flower View Comments

aka Microbial Mystery 005

A 20 year-old female with a pre-existing complete spinal cord injury (C5 ASIA A Ambien Buy, ) from an MVA at the age of 2, presents with a 4 day history of fevers, lethargy, headaches and nausea. She has a long and complex medical history, including a sub-rectus sheath intrathecal baclofen pump inserted 2 years ago, ambien advanced guestbook 2.3.4, several spinal fixation operations for spinal stability (the last 5 years ago), Picture of ambien, and chronic excoriation of both flanks from scratching.

On examination she is GCS 15, her neurological level is unchanged, picture ambien, she has chronic neck stiffness but no photophobia. Ambien zlp 10, She is afebrile, her BP is her usual 90/60 mmHg, HR 100/min, ambien improves memory. Sats 97% RA, Tryptophan ambien, RR 14/min. Apart from the scratch marks, the rest of her skin is intact with no pressure areas, Ambien Buy. Respiratory, cardiovascular, legal ambien us pharmacy, gastrointestinal, Generic ambien without perscription, genitourinary and musculoskeletal exams are unremarkable.

Initial investigations reveal an elevated WCC and CRP.