George Sternbach

The glasgow coma scale

Teasdale and Jennett first presented the Glasgow Coma Scale in 1974 as an aid in the clinical assessment of unconsciousness. It was devised as a formal scheme to overcome the ambiguities and misunderstandings that arose when information about comatose patients was presented and groups of patients were compared. Since then, the Glasgow Coma Scale has been used extensively, being used to grade individual patients, compare effectiveness of treatments, and as a prognostic indicator. It has been incorporated into numerous trauma and critical illness classification systems. However, a number of competing scales have been developed to overcome its perceived deficiencies. These scales are generally more complex. One of the expressed reservations regarding the Glasgow Coma Scale has been its failure to incorporate brainstem reflexes. The scale also includes a numerical skew toward the motor response. An important current issue is the appropriate application of the Glasgow Coma Scale to intubated patients. A number of approaches have been used to assign the verbal score to such patients. The timing of initial scoring is another area of discussion. Despite its drawbacks, the Glasgow Coma Scale remains the most universally utilized level of consciousness scale worldwide. It seems destined to be used in emergency medicine for some time.

The history of anthrax.

Anthrax, a potentially fatal infection, is a virulent and highly contagious disease. Descriptions of this disease begin in antiquity, with the best ancient account being by the Roman poet Virgil. During the 19th century, anthrax was the infection involved in several important medical developments. It served as the prototype for Kochs postulates regarding the causation of infectious disease. The first vaccine containing attenuated live organisms was Louis Pasteurs veterinary anthrax vaccine. In the 1900s, human inhalation anthrax occurred sporadically in the United States among textile and tanning workers, but the incidence of the illness had declined dramatically. An outbreak of inhalation anthrax occurred in Sverdlovsk near a Soviet military microbiology facility in 1979. This epidemic represented the largest documented outbreak of human inhalation anthrax in history. In October and November 2001, 22 cases of confirmed or suspected inhalation and cutaneous anthrax were reported associated with the intentional release of the organism in the United States. An additional case of cutaneous disease occurred in March of 2002.

Acute thoracic aortic dissection: The basics

With an increasing incidence, aortic dissection is the most common acute illness of the aorta. In the setting of chronic hypertension, with or without other risk factors for aortic dissection, this diagnosis should be considered a diagnostic possibility in patients presenting to the emergency department with acute chest or back pain. Left untreated, about 75% of patients with dissections involving the ascending aorta die within 2 weeks of an acute episode. But with successful initial therapy, the 5-year survival rate increases to 75%. Hence, timely recognition of this disease entity coupled with urgent and appropriate management is the key to a successful outcome in a majority of the patients. This article reviews acute thoracic aortic dissection, including ED diagnosis and management.

The carpal tunnel syndrome

Chronic carpal tunnel syndrome was initially described by James Jackson Putnam in 1880. A number of medical luminaries have also contributed to our understanding of the syndrome, including Paget, Marie, Ramsay Hunt, Phalen. and Osler. Carpal tunnel syndrome is the most common peripheral compression neuropathy. Most cases are idiopathic, with nonspecific tenosynovitis leading to median nerve compression. A number of diseases and other conditions are also associated with chronic carpal tunnel. Patients characteristically complain of nocturnal paresthesias or burning pain. Motor complaints relate to thenar muscular weakness and atrophy. Bedside diagnostic tests include Tinels and Phalens signs, and application of pressure over the median nerve by inflating a sphygmomanometer over the wrist. Tinels sign is the induction of paresthesias by tapping over the site of the median nerve at the wrist. In Phalens sign, symptoms are reproduced by maximum flexion of the wrist for 60 s. The classically described patients are middle-aged women. In addition, another distinct population is receiving increased attention, the relatively young male and female workers who experience symptoms performing repetitive manual labor.

Rupert waterhouse and carl friderichsen: adrenal apoplexy☆

The Waterhouse-Friderichsen (WFS) syndrome, also known as purpura fulminans, is described as acute hemorrhagic necrosis of the adrenal glands and is most often caused by meningococcal infection. This clinical entity is more frequently seen in the pediatric than the adult population and is associated with a high morbidity and mortality. The initial presenting complaints for patients with the WFS usually include a diversity of nonspecific, vague symptoms such as cough, dizziness, headache, sore throat, chills, rigors, weakness, malaise, restlessness, apprehension, myalgias, arthralgias, and fever. These symptoms are usually abrupt in their onset. Petechiae are present in approximately 50-60% of patients. The clinical diagnosis of WFS may be relatively straightforward or extremely challenging. Patients who appear in the initial and nontoxic-appearing stage without any skin lesions may be difficult to distinguish from a benign viral illness. When a patient presents with fever and petechiae, WFS must be considered, even when the patient has a non-toxic appearance. Due to the rapid progression and often devastating consequences, therapy should be instituted as soon as the diagnosis is suspected.

Management of increased intracranial pressure : A review for clinicians

Emergency physicians are frequently confronted with head-injured patients, many of whom have intracranial hypertension. Since direct correlations have been reported between increased intracranial pressure (ICP) and adverse outcome, it is important to rapidly identify and treat these patients. Furthermore, since the actual brain damage that occurs at the time of injury cannot be modified, the maximization of neurological recovery depends upon minimizing secondary insults to the brain, most notably preventing hypotension and hypoxemia. Volume resuscitation to maintain an adequate mean arterial pressure, airway control, and sedation and analgesia to prevent surges in ICP remain the cornerstone of early management. These principles and the emergency department management of the head-injured patient are reviewed in this paper.

Automatic external defibrillators : lessons from the past, present and future

Coronary artery disease remains the leading cause of death in the United States and most developed countries. Many of the victims die from sudden cardiac arrests, resulting from dysrhythmias-most commonly ventricular fibrillation. Since most cardiac arrests occur outside the hospital, implementing emergency services in the field will have a great impact on survival. With the development of the modern automatic external defibrillator (AED), early recognition and correction of these dysrhythmias by lay rescuers can significantly improve outcome from sudden death. This paper reviews the past, present and future development and applications of AEDs.

Thyrotoxic periodic paralysis

We present the case of a 21-year-old man who presented to the emergency department with an episode of profound weakness due to thyrotoxic periodic paralysis, a syndrome of muscular weakness occurring in patients with hyperthyroidism. Prior to the diagnosis, the patient was treated with a parenteral tranquilizer. When hypokalemia was discovered, potassium was administered, resulting in the development of hyperkalemia. Episodes of thyrotoxic periodic paralysis are usually self limited, and recovery of motor strength is complete. However, potassium is frequently administered to hasten recovery and prevent cardiac arrhythmias and respiratory arrest. Serum potassium must, therefore, be monitored carefully in these patients during treatment.

Nalmefene : a long-acting opioid antagonist. Clinical applications in emergency medicine

The use of the opioid antagonist naloxone is well known to the experienced health care provider. The availability of the longer acting opioid antagonist nalmefene has several potential benefits in clinical practice. Nalmefene has a plasma half-life of almost 11 h, compared to 60-90 min for naloxone. Nalmefene has been shown to reverse opioid intoxication for as long as 8 h, reducing the need for continuous monitoring of intoxicated patients and repeated dosing of naloxone. Single dose administration has also been used effectively in the reversal of opiate-assisted conscious sedation. In addition, this agent has been used in the treatment of diseases as diverse as interstitial cystitis and chronic alcohol dependence. However, the long duration of action enables extended withdrawal reactions in the chronically opioid-dependent patient. The prolonged opioid antagonism of nalmefene has several applications in the clinical practice of emergency medicine, and is a useful addition in certain situations to the pharmacologic armamentarium of the practicing emergency physician.

CARBON MONOXIDE POISONING : AN OCCULT EPIDEMIC

Carbon monoxide poisoning is a significant health threat in the United States. Smoke inhalation from fires is the most common source. History of carbon monoxide exposure and elevated carboxyhemoglobin levels should alert physicians to the diagnosis of acute poisoning. When there is no history of exposure, carbon monoxide poisoning must be considered when two or more patients are similarly or simultaneously sick. The diagnosis must be excluded by a directed history and physical examination. If suspicion remains, carboxyhemoglobin levels should be determined and oxygen therapy should be started empirically while laboratory results are pending. Prompt administration of hyperbaric oxygen may reduce the risk of death. If carbon monoxide poisoning is confirmed, the source must be identified and recommendations for correction or avoidance should be made.