Ketamine for palliative sedation in the emergency department.

Background: Palliative sedation to treat severely distressing symptoms in those with a poor prognosis is well-accepted.

Objective: We discuss palliative sedation in the Emergency Department and the use of ketamine.

Case Report: We present the case of a patient with angioedema of the tongue and severe respiratory distress.

A case of Evans' syndrome following influenza vaccine.

Background: Evans' syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia purpura and autoimmune hemolytic anemia with a positive direct antiglobulin test in the absence of known underlying etiology.

Objectives: We present a case of Evans' syndrome following influenza vaccination.

Case Report: A 50-year-old man with no prior medical history developed Evans' syndrome 4 days after receiving influenza immunization.

How (un)useful is the pelvic ring stability examination in diagnosing mechanically unstable pelvic fractures in blunt trauma patients?

Objectives: Our goal was to evaluate the utility of the pelvic ring stability examination for detection of mechanically unstable pelvic fractures in blunt trauma patients.

Methods: Retrospective chart review.

Results: We enrolled 1,502 consecutive blunt trauma patients and found 115 patients with pelvic fractures including 34 patients with unstable pelvic fractures (Tile classification B and C).

Intravenous ketamine in a dissociating dose as a temporizing measure to avoid mechanical ventilation in adult patient with severe asthma exacerbation.

Background: Patients experiencing severe asthma exacerbations occasionally deteriorate to respiratory failure requiring endotracheal intubation and mechanical ventilation. Mechanical ventilation in this setting exposes the patients to substantial iatrogenic risk and should be avoided if at all possible.

Objectives: To describe the use of intravenous ketamine in acute asthma exacerbation.

A case of acute keratoconjunctivitis from exposure to latex of Euphorbia tirucalli (pencil cactus).

We present a case of a 40-year-old man who suffered chemical eye injury from the latex of Euphorbia tirucalli (pencil cactus), resulting in acute keratoconjunctivitis. The Euphorbia genus of plants contains numerous species widely distributed throughout all major continents, and therefore this may be a more common Emergency Department occurrence than previously thought.

Lack of evidence to support routine digital rectal examination in pediatric trauma patients.

Background: Current advanced trauma life support guidelines recommend that a digital rectal examination (DRE) should be performed as part of the initial evaluation of all trauma patients. Our primary goal was to estimate the test characteristics of the DRE in pediatric patients for the following injuries: (1) spinal cord injuries, (2) bowel injuries, (3) rectal injuries, (4) pelvic fractures, and (5) urethral disruptions.

Methods: We conducted a nonconcurrent, observational, chart review study of a consecutive series of pediatric trauma patients.

Low diagnostic yield of electrocardiogram testing in younger patients with syncope.

Study Objective: Routine ECG testing is recommended in the evaluation of syncope, although the value of such testing in young patients is unclear. For ECG testing, we assess the diagnostic yield (frequency that ECG identified the reason for syncope) and predictive accuracy for 14-day cardiac events after an episode of syncope as a function of age.

Methods: Adult patients with syncope or near-syncope were prospectively enrolled for 1 year at a single academic emergency department (ED).

Poor test characteristics for the digital rectal examination in trauma patients.

Study Objective: Current advanced trauma life support guidelines recommend that a digital rectal examination be performed as part of the initial evaluation of all trauma patients. Our goal is to estimate the test characteristics of the digital rectal examination in trauma patients.

Methods: We conducted a retrospective medical record review study of consecutive trauma patients treated in our emergency department from January 2003 to February 2005 for whom the trauma team was activated and who had a documented digital rectal examination.

Blind urethral catheterization in trauma patients suffering from lower urinary tract injuries.

Objectives: The goals of our study were to review all cases of urethral and bladder trauma that presented to the University of California, Los Angeles (UCLA) Medical Center between January 1998 and August 2005 and determine (1) the clinical characteristics of patients with urethral and/or bladder injuries as well as the sensitivities of those clinical characteristics; (2) whether or not a blind attempt to insert a urethral catheter was performed; and (3) whether there is any evidence that a blind attempt to insert a urethral catheter worsened the initial urinary tract injury.

Methods: This is a retrospective chart review.

Results: The study cohort comprised 46 patients with a mean age of 30 years, including 36 men (78.

External validation of the San Francisco Syncope Rule.

Study Objective: We externally validate the ability of the San Francisco Syncope Rule to accurately identify syncope patients who will experience a 7-day serious clinical event.

Methods: Patients who presented to a single academic emergency department (ED) between 8 am and 10 pm with syncope or near-syncope were prospectively enrolled. Treating physicians recorded the presence or absence of all San Francisco Syncope Rule risk factors.

Delayed obstruction of endotracheal tubes by aspirated foreign bodies: report of two cases.

We present 2 cases of endotracheal tube obstruction as a result of previously aspirated foreign bodies that moved from the bronchial tree into the endotracheal tube. The signs of endotracheal tube obstruction were demonstrated in both cases: (1) activation of the high-pressure alarm; (2) difficulty ventilating by using a bag-valve-mask device; (3) rapid decrease of end-tidal CO2; (4) oxygen desaturation that may have lagged behind the decrease of end-tidal CO2; and (5) the inability to advance a catheter down the endotracheal tube. The differential diagnosis of endotracheal tube obstruction is discussed, as are possible interventions to remove the obstruction and secure an open airway.

In vitro ultrasound augmented clot dissolution--what is the optimal timing of ultrasound application?

The mechanism of ultrasound augmentation of pharmacological thrombolysis is yet unknown. The goal of this study is to find the best timing regimen for in-vitro ultrasound augmented clot dissolution by streptokinase, heparin and their combination. Blood clots from 4 donors were cut into 200-400 mg sections and randomized to no treatment with ultrasound; pre-treatment with ultrasound (before immersion); early treatment with ultrasound; or late treatment with ultrasound.

"Suffocation roulette": a case of recurrent syncope in an adolescent boy.

We present the case of a 12-year-old boy admitted with a complaint of recurrent syncopal episodes. A careful history taking revealed the cause of the syncopal episodes to be a dangerous game played by adolescents called "suffocation roulette." We believe that recognition of this game as a possible cause of syncopal events, together with prompt educative intervention, might prevent adolescent morbidity and mortality and also might eliminate the need for unnecessary medical investigations.