Jonathan S. Olshaker

The erythrocyte sedimentation rate

The erythrocyte sedimentation rate has been used for over 50 years for everything from predicting disease severity to assessing general sickness index. Its perceived utility has been based on medical myths and its use too often based only on a consultants demand or a shotgun approach to diagnosis. This article focuses on examining the specific utility of the erythrocyte sedimentation rate in the emergency department as a tool for predicting both disease likelihood and severity.

Prescription noncompliance: contribution to emergency department visits and cost.

We randomly surveyed 100 patients in the acute care section of a large urban university hospital Emergency Department (ED) on 6 days with regard to the existence of and reasons for prescription noncompliance. Noncompliance was considered a major factor contributing to the ED visit if: (1) no medications had been taken for at least 48 h before the ED visit; (2) the medications, when previously taken, had routinely controlled the condition for which the patient was presenting to the ED; and (3) no other significant cause or illness was believed to have precipitated the ED visit. ED, admissions, and yearly medication costs were calculated for all patients. Noncompliance was found to be a contributing factor in the cases of 22 patients (22%). The most common medications involved were phenytoin and albuterol. Cost was the most common reason for noncompliance (11 [50%]). The average ED charge per noncompliant patient discharged was

Delayed presentation of splenic rupture after colonoscopy.

576.61. Six noncompliant patients were admitted at an average cost of

Rhinocerebral mucormycosis: A case of a rare, but deadly disease

4,834.62. The average cost of a years medication was

The efficacy and safety of a continuous albuterol protocol for the treatment of acute adult asthma attacks

520.72. Noncompliance with drug prescriptions is a significant contributor to ED visits and health care costs.

Baseball bat assault injuries.

Splenic rupture is a rare but potentially deadly complication of colonoscopy. We present the case of a 70-year-old male who presented with abdominal pain, initially stable, almost 2 days after colonoscopy. The patients clinical status deteriorated shortly after abdominal CT scan identified splenic rupture.

Delayed cardiac tamponade after pacemaker insertion

Rhinocerebral mucormycosis is a rare fungal infection of the nasal cavity and sinuses that can spread to the orbits and cranium within days. Its presentation can be confused with those of sinusitis, viral infections, diabetic ketoacidosis, or carotid sinus thrombosis, and it is often missed at early presentation. Survival is directly linked to early detection and treatment. We present a case of rhinocerebral mucormycosis and discuss the literature on its early signs and symptoms, pathophysiology, and treatment options.

Acute pancreatitis following lisinopril rechallenge.

We performed a prospective study over a 6-month period to test the efficacy and safety of a continuous nebulized albuterol protocol for the treatment of acute adult asthma attacks. All patients 18 years or older presenting to the emergency department with acute asthma attacks were begun by the triage nurse on the protocol of three continuous albuterol (2.5 mg) nebulizer treatments. Pretreatment and posttreatment peak flow, respiratory rate, pulse, and blood pressure were documented and patients gave a pretreatment and posttreatment rating of the clinical severity of their attack using a (1 to 10) visual analog scale. In addition, all adverse effects were noted. Seventy-six patients were entered in the study. The average age was 44 years (range, 20 to 82 years). Pretreatment and posttreatment peak flow, respiratory rate, pulse, blood pressure, and clinical severity were compared using the paired t test. Patients showed statistically significant increases in peak flow (128 to 292; P < .0001) and statistically significant decreases in respiratory rate (27 to 20; P < .0001); pulse, 103 to 94 (P < .0001); clinical severity, 7.8/10 to 1.8/10 (P < .0001); and blood pressure, 141/82 to 132/77 (P < .001). Adverse effects were minimal. Two patients (2.6%) felt flushed, three patients (4%) felt jittery, and one patient (1.3%) had a sensation of palpitations. We conclude that a continuous nebulized albuterol protocol is both extremely efficacious and safe for the treatment of acute adult asthma attacks.

Introduction to the new section “Clinical Laboratory in Emergency Medicine” Emergency department pregnancy testing☆

The baseball bat, according to Baltimore City police crime statistics, is a commonly used weapon. To assess the severity of injuries inflicted by this modern-day club, we retrospectively reviewed 75 charts of patients treated at the University of Maryland Medical Systems Hospital for baseball bat injuries from January 1990 through July 1991. Multisystem trauma was documented, with craniocerebral injury being the most frequent and the most frequent cause of death. Of the victims struck on the head, 26% sustained an intracranial hemorrhage. In our series, the history of loss of consciousness and the Glasgow Coma Scale score failed to reliably identify the patients with serious injuries. Seventeen percent of our patients with intracranial hemorrhages had both a negative or uncertain history of loss of consciousness and a normal Glasgow Coma Scale score on arrival.

Simultaneous uvulitis and epiglottitis without fever or leukocytosis.

Cardiogenic shock is one of the most dramatic presentations in Emergency Medicine and requires rapid and accurate assessment, evaluation, and treatment. The cardiovascular disasters that present with shock include acute myocardial infarction with pump failure, aortic dissection, massive pulmonary emboli, and cardiac tamponade. We report a patient who presented to our Emergency Department (ED) in cardiogenic shock 10 days after insertion of a permanent cardiac pacemaker. The patient had developed pericardial tamponade secondary to the insertion. In reviewing the literature, we found many reports relating to complications of pacemakers and even more information regarding the various etiologies of cardiac tamponade, but cardiac tamponade as a consequence of pacemaker insertion rarely has been reported. Cardiac tamponade can occur secondary to perforation of the right ventricle during pacemaker electrode insertion and manipulation. Perforation is generally believed to be benign and self-limiting and only rarely causes tamponade and hemodynamic compromise; however, that was not the case for our patient.