Frank J. Baker

Magnesium: Physiology, Clinical Disorders, and Therapy

Magnesium imbalance is clinically significant. It is common, treatable, and frequently overlooked. We review the literature describing magnesium deficit and excess syndromes and formulate specific treatment protocols.

Cranial burr hole decompression in the emergency department

Presently virtually all patients with acute head trauma are computed tomography (CT) scanned and transferred to a neurosurgical operating room before any surgical intervention. The time required for this, especially if the patient is transferred to another institution, may lead to a significant delay in treatment. In a patient with an expanding intracranial hematoma and evidence of brainstem compromise this delay may produce a worse outcome. Cranial burr hole placement can rapidly, safely, and accurately find and partially decompress most extracerebral intracranial hematomas. A burr hole placed rapidly before CT and transfer could prevent further damage to the brain by an expanding hematoma. The case of a child with a preterminal epidural hematoma whose outcome was excellent because of a burr hole placed in the emergency department (ED) is presented. In light of this case and a complete literature review, it is suggested that more frequent attempts to decompress intracranial hematomas in the ED may be warranted.

Pulsus paradoxus as a parameter in treatment of the asthmatic

In 40 patients treated in the Billings Hospital emergency department for acute exacerbations of bronchial asthma, pulsus paradoxus was noted at presentation and at the time of admission to the hospital or discharge. No level of initial pulsus paradoxus predicting eventual admission was found. High initial pulsus paradoxus was more frequent in admitted patients. A correlation between the percent drop of pulsus paradoxus and success or failure of treatment was noted. Treatment failure was the most frequent criterion for admission.

Alcoholic ketoacidosis in a pregnant woman.

A case of alcoholic ketoacidosis in a 23-year-old chronic alcoholic, gravada V, para IV, is reported. Symptoms were constant, severe, nonradiating pain with crampy exacerbations, anorexia, nausea and vomiting. The patient had a tender and irritable full-term uterus. She was treated inhospital with vigorous fluid therapy and 5% dextrose in normal saline, sodium bicarbonate, glucose and insulin and showed improvement overnight. Alcoholic ketoacidosis has not been reported in pregnant women. Metabolic derangements combine to produce ketoacidosis more readily in the pregnant alcoholic. Differentiation of alcoholic ketoacidosis and diabetic ketoacidosis is important since treatment varies. For alcoholic ketoacidosis, treatment is vigorous rehydration with dextrose-saline while diabetic ketoacidosis usually requires multiple therapeutic modalities.

The emergency joint: Arthrocentesis and synovial fluid analysis*

Arthrocentesis and the subsequent evaluation of synovial fluid is often the definitive diagnostic procedure for the patient presenting with a joint effusion or intrasynovial hemorrhage. The difficulty of performing arthrocentesis varies with the joint in question, but those joints most frequently involved are easily entered. The indications and contraindications for this procedure are discussed. Effusion-producing pathologic processes often yield fluids of a characteristic nature permitting their classifications into categories of noninflammatory (Group I), inflammatory (Group II), septic (Group III), and hemorrhagic. This categorization of the effusion may permit specific diagnosis or the narrowing of the differential diagnosis. Criteria are established on the basis of joint fluid features to differentiate septic arthritis, which requires inpatient treatment, from those entities for which the patient may reasonably be treated as an outpatient.

Diabetic emergencies: hypoglycemia and ketoacidosis.

Because hypoglycemia may be rapidly fatal it must be diagnosed and treated early. Ketoacidosis may be difficult to differentiate from hypoglycemia. The diagnosis, treatment and causes of both diabetic emergencies are described. Once rehydration is instituted, further management can be directed using appropriate laboratory and bedside studies that allow stabilization with a high degree of control.

The Use of an Aeromedical Service for the Transport of Patients on Intra-aortic Balloon Pumps in the Regionalization of Medical Care

On 1 March 1987 the University of Chicago initiated transport of patients on intra-aortic balloon pumps using a hospital-based rotorcraft. In the subsequent eight months, 8 patients have been transported. The indications, complications, and survival of this patient group will be discussed. The selection and training of professional staff necessary to accomplish this mission will be discussed.

Aeromedical Crashes in the United States: An Epidemic of Recklessness or the Cost of Doing Business?

Alcohol is a major factor in MVA fatalities in the industrialized world. In Canada, about 50% of all drivers killed had been drinking. Unfortunately, we have no good comparative figures for non-fatal injuries. What few studies are available, have major methodological problems such as high percentages of nonrespondents. Because of the dearth of information available on MVA injuries, the Ontario Sunnybrook Medical Centre Trauma Unit and the Addiction Research Foundation have embarked on a large-scale study on trauma victims. The purposes of the study are threefold: 1) to examine in a systematic way the injuries, recovery process and the factors such as blood alcohol levels (BACs), etc., that are related to injury severity and recovery; 2) the psychosocial characteristics of trauma victims; and 3) the longterm consequences of trauma on the victims. Preliminary findings from the first part of the study will be the focus of this presentation. Our paper will offer data on: 1) demographic characteristics; 2) injury severity and recovery ratings; and 3) BACs of all trauma victims admitted to the Sunnybrook Medical Centre Trauma Unit over a 6 month period. For example, of the approximately 200 MVA trauma admissions, 40% tested BAC positive, with the summer months representing the higher levels of positive BACs. The relationships among the variables will be highlighted.