Speciality
Spotlight

 




 

Critical Medicine – Emergency Medicine

 

 





Organ
System Emergencies

     

  • K Chen, J
    Varon, OC Wenker (Univ of Texas, Houston; Baylor College of Medicine, Houston)


    Malignant Airway Obstruction : Recognition and Management.


    J Emerg Med 16: 83-92, 1998.

      


    Malignant airway obstruction can develop in patients with primary malignant tumours or metastatic tumours of the head and neck, respiratory tract or
    mediastinum. This study reviews the causes,
    pathophysiology, clinical manifestations, diagnosis and management of malignant airway obstruction. The commonest cause – lung tumours – can cause obstruction by extrinsic or intrinsic compression caused by the tumour itself or enlarged lymph nodes.
    Dyspnoea, haemoptysis and post-obstructive pneumonia are the 3 commonest presentations.

      


    The primary aim is to establish a patent airway and palliate symptoms. It should always be remembered that an initial diagnosis of reactive airway disease, asthma or CCF may precede the true diagnosis.

      


    DO’s and DON’Ts of Malignant Airway Obstruction

     


    DO :

    1) Allow position changes

    2) Keep multiple sized ET tubes available

    3) Awake establishment of airway, if possible.

    4) Different size bronchoscopes

    5) Detailed radiological evaluations – CT, MRI

    6) Consult thoracic, head & neck surgeons and anesthesiologists.

     


    DON’T :

    1) Use respiratory depressing sedatives and muscle relaxants.

    2) Induce General anesthesia

    3) Positive pressure ventilates till obstruction is relieved

     

  • RA Pauwels,for the Formoterol and Corticosteroids Establishing Therapy
    (FACET)International study group (Univ Hosp. Ghent, Belgium)


    Effect of Inhaled Formoterol and Budesonide on Exacerbations of Asthma


    N Engl J Med 337: 1405-1411, 1997.

      


    The first-line treatment for patients with moderate to severe persistent asthma is inhaled
    glucocorticoids, but many patients continue to have symptoms and need additional treatments. This broad-based, double-blind,
    randomised, parallel group study has included 4 treatment groups. Their suggestion that long acting, inhaled b2- agonist to inhaled glucocorticoid would produce symptomatic improvement without long-term negative effects is aptly supported by the results. It is advisable to give a trial of maximal dose of inhaled glucocorticoids prior to the addition of inhaled long acting b2-agonists. Such studies form a good platform for laying down guidelines. However, individualisation remains a commonly used option in initial treatment.

      

  • GV Heller, SA
    Stowers, RC Hendel, et al (Univ of Connecticut, Farmington; St Luke’s Med
    Ctr, Jacksonville, Fla; Northwestern Univ, Chicago; et al)


    Clinical Value of Acute Rest Technetium-99m Tetrofosmin Tomographic Myocardial Perfusion Imaging in Patients with Acute Chest Pain and Nondiagnostic Electrocardiograms.


    J Am Coll Cardiol 31:1011-1017, 1998.

     


    Stress testing in Acute Myocardial Infarction is not without its due risk. Cardiac imaging is beneficial in this case. SPECT has a higher sensitivity and specificity. Technetium is better than thallium because of better image quality and nonredistribution of the radioisotope. Although the sensitivity and negative predictive values of the study are impressive, the study population appears to have been highly
    selected. Also, the study does not compare SPECT over CK-MB and troponin or both determinations.

     

  • MC
    Kontos, RL Jesse, KL Schmidt, et al (Virginia Commonwealth
    Univ, Richmond)


    Value of Acute Rest Sestamibi Perfusion Imaging for Evaluation of Patients Admitted to the Emergency Department with Chest Pain.


    J Am Coll Cardiol 30: 976-982, 1997.

      


    This study has evaluated patients at the ED with acute chest pain, subjecting them to early perfusion imaging with Tc-99m
    sestamibi. They have shown that a positive result on perfusion imaging was 93% sensitive for MI and 81% for
    MI/revascularisation. Negative predictive values were 99% for sensitivity and 95% for specificity. Although, the study shows impressive results, it does not address the cost effectiveness of the rest imaging.

       

  • M Ryan, DH
    Rhoney, MS Luer, et al (Univ of Kentucky, Lexington; Univ of Arkansas, Little Rock; Detroit Receiving Hosp)


    New and Investigational Treatment Options for Ischemic Stroke


    Pharmacotherapy 17: 959-969, 1997.

     


    The article outline new treatment strategies and experimental therapies for stroke which is the commonest cause of adult disability in the United States. The authors have conducted a Medline search from the 1989-1996 period. The search yielded

     


    1. Thrombolytic therapy: rt-PA

    – to be started within 3 hours of onset

    – requires intense patient monitoring.

     


    2. Glutamate

    – BW-619C89, a glutamate release inhibitor is in phase II trials.

    – Namefone, reduces glutamate levels, in clinical trials.

    – Lubeluzole, may inhibit glutamate induced NO production is under preliminary testing.

      


    3. NMDA Antagonists:

    – Cerestat, CNS-1102, undergoing clinical safety trials.

    – The drug has significant adverse effects.

     


    4. Calcium Channel Blockers:

    – have had disappointing results in the studies conducted.

     


    5. Gangliosides:

    GM1 – is an endogenous brain membrane component that stimulates neuronal sprouting and differentiation. The clinical trials have been inconclusive.

      


    6. Free Radical Scavengers:

    – are generated by ischaemic tissue and cause neuronal damage.

    – Tirilazad is undergoing preliminary clinical trials.

      


    7. Membrane Stabilizers:

    Citicholine monosodium has shown good results in preliminary trials.

      


    8. ICAM-1 Antagonists:

    Enlimomab binds the ICAM-1 receptor and reduces neutrophil accumulation.

      


    9. Growth factors: under research.

      

  • NZ
    Mian, R Bayly, DM Schreck, etal (Muhlenberg Regional Med
    Ctr, Plain-field, NJ)


    Incidence of Deep Venous Thrombosis Associated with Femoral Venous Catheterization.


    Acad Emerg Med 4:1118-1121, 1997

      


    The study evaluated 42 patients admitted over a 14-month period subjected to a Heparin-coated 7-fr 20-cm femoral venous catheters. Each patient was subjected to a venous duplex sonography within 7 days of catheter removal. 

      


    Although the study has shown 26% of patients to develop DVT, it does not justify the patients undergoing femoral vein catheterization to be subjected to studies for hypercoaguble states. There is always the potential for substantial morbidity following femoral vein catheterization. Hence, the risk and benefit must be considered prior to this procedure, and complications must be anticipated.

       


 



 

 

Speciality Spotlight

 

 

Organ System Emergencies
     

  • K Chen, J Varon, OC Wenker (Univ of Texas, Houston; Baylor College of Medicine, Houston)
    Malignant Airway Obstruction : Recognition and Management.
    J Emerg Med 16: 83-92, 1998.
      
    Malignant airway obstruction can develop in patients with primary malignant tumours or metastatic tumours of the head and neck, respiratory tract or mediastinum. This study reviews the causes, pathophysiology, clinical manifestations, diagnosis and management of malignant airway obstruction. The commonest cause – lung tumours – can cause obstruction by extrinsic or intrinsic compression caused by the tumour itself or enlarged lymph nodes. Dyspnoea, haemoptysis and post-obstructive pneumonia are the 3 commonest presentations.
      
    The primary aim is to establish a patent airway and palliate symptoms. It should always be remembered that an initial diagnosis of reactive airway disease, asthma or CCF may precede the true diagnosis.
      
    DO’s and DON’Ts of Malignant Airway Obstruction
     
    DO :
    1) Allow position changes
    2) Keep multiple sized ET tubes available
    3) Awake establishment of airway, if possible.
    4) Different size bronchoscopes
    5) Detailed radiological evaluations – CT, MRI
    6) Consult thoracic, head & neck surgeons and anesthesiologists.
     
    DON’T :
    1) Use respiratory depressing sedatives and muscle relaxants.
    2) Induce General anesthesia
    3) Positive pressure ventilates till obstruction is relieved
     

  • RA Pauwels,for the Formoterol and Corticosteroids Establishing Therapy (FACET)International study group (Univ Hosp. Ghent, Belgium)
    Effect of Inhaled Formoterol and Budesonide on Exacerbations of Asthma
    N Engl J Med 337: 1405-1411, 1997.
      
    The first-line treatment for patients with moderate to severe persistent asthma is inhaled glucocorticoids, but many patients continue to have symptoms and need additional treatments. This broad-based, double-blind, randomised, parallel group study has included 4 treatment groups. Their suggestion that long acting, inhaled b2- agonist to inhaled glucocorticoid would produce symptomatic improvement without long-term negative effects is aptly supported by the results. It is advisable to give a trial of maximal dose of inhaled glucocorticoids prior to the addition of inhaled long acting b2-agonists. Such studies form a good platform for laying down guidelines. However, individualisation remains a commonly used option in initial treatment.
      

  • GV Heller, SA Stowers, RC Hendel, et al (Univ of Connecticut, Farmington; St Luke’s Med Ctr, Jacksonville, Fla; Northwestern Univ, Chicago; et al)
    Clinical Value of Acute Rest Technetium-99m Tetrofosmin Tomographic Myocardial Perfusion Imaging in Patients with Acute Chest Pain and Nondiagnostic Electrocardiograms.
    J Am Coll Cardiol 31:1011-1017, 1998.
     
    Stress testing in Acute Myocardial Infarction is not without its due risk. Cardiac imaging is beneficial in this case. SPECT has a higher sensitivity and specificity. Technetium is better than thallium because of better image quality and nonredistribution of the radioisotope. Although the sensitivity and negative predictive values of the study are impressive, the study population appears to have been highly selected. Also, the study does not compare SPECT over CK-MB and troponin or both determinations.
     

  • MC Kontos, RL Jesse, KL Schmidt, et al (Virginia Commonwealth Univ, Richmond)
    Value of Acute Rest Sestamibi Perfusion Imaging for Evaluation of Patients Admitted to the Emergency Department with Chest Pain.
    J Am Coll Cardiol 30: 976-982, 1997.
      
    This study has evaluated patients at the ED with acute chest pain, subjecting them to early perfusion imaging with Tc-99m sestamibi. They have shown that a positive result on perfusion imaging was 93% sensitive for MI and 81% for MI/revascularisation. Negative predictive values were 99% for sensitivity and 95% for specificity. Although, the study shows impressive results, it does not address the cost effectiveness of the rest imaging.
       

  • M Ryan, DH Rhoney, MS Luer, et al (Univ of Kentucky, Lexington; Univ of Arkansas, Little Rock; Detroit Receiving Hosp)
    New and Investigational Treatment Options for Ischemic Stroke
    Pharmacotherapy 17: 959-969, 1997.
     
    The article outline new treatment strategies and experimental therapies for stroke which is the commonest cause of adult disability in the United States. The authors have conducted a Medline search from the 1989-1996 period. The search yielded
     
    1. Thrombolytic therapy: rt-PA
    – to be started within 3 hours of onset
    – requires intense patient monitoring.
     
    2. Glutamate
    – BW-619C89, a glutamate release inhibitor is in phase II trials.
    – Namefone, reduces glutamate levels, in clinical trials.
    – Lubeluzole, may inhibit glutamate induced NO production is under preliminary testing.
      
    3. NMDA Antagonists:
    – Cerestat, CNS-1102, undergoing clinical safety trials.
    – The drug has significant adverse effects.
     
    4. Calcium Channel Blockers:
    – have had disappointing results in the studies conducted.
     
    5. Gangliosides:
    GM1 – is an endogenous brain membrane component that stimulates neuronal sprouting and differentiation. The clinical trials have been inconclusive.
      
    6. Free Radical Scavengers:
    – are generated by ischaemic tissue and cause neuronal damage.
    – Tirilazad is undergoing preliminary clinical trials.
      
    7. Membrane Stabilizers:
    Citicholine monosodium has shown good results in preliminary trials.
      
    8. ICAM-1 Antagonists:
    Enlimomab binds the ICAM-1 receptor and reduces neutrophil accumulation.
      
    9. Growth factors: under research.
      

  • NZ Mian, R Bayly, DM Schreck, etal (Muhlenberg Regional Med Ctr, Plain-field, NJ)
    Incidence of Deep Venous Thrombosis Associated with Femoral Venous Catheterization.
    Acad Emerg Med 4:1118-1121, 1997
      
    The study evaluated 42 patients admitted over a 14-month period subjected to a Heparin-coated 7-fr 20-cm femoral venous catheters. Each patient was subjected to a venous duplex sonography within 7 days of catheter removal. 
      
    Although the study has shown 26% of patients to develop DVT, it does not justify the patients undergoing femoral vein catheterization to be subjected to studies for hypercoaguble states. There is always the potential for substantial morbidity following femoral vein catheterization. Hence, the risk and benefit must be considered prior to this procedure, and complications must be anticipated.
       

 

 

By |2022-07-20T16:42:18+00:00July 20, 2022|Uncategorized|Comments Off on Organ System Emergency

About the Author: