Myasthenia gravis presenting as a unilateral abducens nerve palsy.

A 48-year-old man with no significant medical history presented to the emergency department of a large, urban, tertiary-care hospital complaining of double vision and unsteady gait. Physical examination was remarkable for an isolated, unilateral sixth nerve palsy. After comprehensive testing, a final diagnosis of myasthenia gravis was made. The patient's unsteady gait was a manifestation of sensory distortion from the diplopia and corrected when the patient closed his eyes. The presentation of myasthenia gravis as an isolated sixth nerve palsy is unprecedented in the emergency medicine literature.

Advances in the genetics of cerebrovascular disease and stroke.

MEDLINE searches identified epidemiologic, experimental, and clinical studies on the genetics of cerebrovascular disease and stroke, including the following topics: genetic epidemiology of stroke; genetics of systemic disorders that cause ischemic stroke, including coagulation disorders, connective tissue disorders, vasculopathies, metabolic disorders, and disorders of unknown etiology; and genetics of systemic disorders that cause hemorrhagic stroke. Recent discoveries in stroke genetics involve the genetic basis of monogenic disorders such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy and sickle cell disease. Reproducing similar advances in other forms of cerebrovascular disease and stroke will be more difficult because their inheritance is complex, multigenic, and heterogeneous. However, the future is promising with the application of molecular genetic approaches such as linkage analysis, allele-sharing methods, association studies, and polygenic analysis of experimental crosses as well as the transmission/disequilibrium test--a statistical method for detection of linkage between a marker and a disease-susceptibility locus.

Graduate medical education downsizing: perceived effects of participating in the HCFA demonstration project in New York State.

OBJECTIVE: Financial support for graduate medical education (GME) is shrinking nationally as Medicare cuts GME funds. Thirty-nine hospitals in New York State (NYS) voluntarily participated in a Health Care Financing Administration demonstration project (HCFADP)-the goal of which was to reduce total residency training positions by 4-5%/year over a five-year period, while increasing primary care positions. The objective of this study was to determine the effect of downsizing on emergency department (ED) staffing and emergency medicine (EM) residency training. METHODS: Structured interviews and surveys of NYS program directors (PDs) were conducted in October-December 1999. Simple frequencies are reported. RESULTS: One hundred percent of 17 PDs completed the interviews and seven of 12 participants in the HCFADP returned surveys. Twelve of 17 programs participated in HCFADP and two programs downsized outside HCFADP. Seven of 12 participants lost EM positions. Six of 12 programs were forced to exclude outside residents from rotating in their ED, leading to a need for one participating program and one non-participating program to find alternative sites for trauma. Five of 12 institutions provided resident staffing data, reporting a reduction in ED resident coverage in year 1 of the project of 9-40%. Programs compensated by increasing the number of shifts worked (4/12), increasing shift length (1/12), decreasing pediatric ED shifts (1/12), decreasing elective or research time (2/12), and decreasing off-service rotations (4/12). Six departments hired physician assistants or nurse practitioners, two hired faculty, and two hired resident moonlighters. Six of 12 programs withdrew from HCFADP and returned to previous resident numbers. Eight of 12 PDs thought that they had decreased time for clinical teaching. CONCLUSIONS: A 4-5% reduction in residency positions was associated with a marked reduction in ED resident staffing and EM residency curriculum changes.

Refractory priapism of unknown etiology in a pediatric patient.

Priapism is a urologic emergency that can occur in any age group and every patient should receive prompt urologic consultation. Management of priapism is based on the recognition of underlying pathophysiology; ready differentiation between high-flow and low-flow priapism; reversal of any potential precipitating factors; the use of corporal aspiration irrigation combined with intracavernosal alpha adrenergic therapy; and when necessary, a shunting procedure. Delay in recognition or treatment can be crucial as the incidence of long-term complication rises substantially with the duration of the priapism.

Recommendations for the establishment of primary stroke centers. Brain Attack Coalition.

OBJECTIVE: To develop recommendations for the establishment and operation of primary stroke centers as an approach to improve the medical care of patients with stroke. PARTICIPANTS: Members of the Brain Attack Coalition (BAC), a multidisciplinary group of representatives from major professional organizations involved with delivering stroke care. Supplemental input was obtained from other experts involved in acute stroke care. EVIDENCE: A review of literature published from 1966 to March 2000 was performed using MEDLINE. More than 600 English-language articles that had evidence from randomized clinical trials, meta-analyses, care guidelines, or other appropriate methods supporting specific care recommendations for patients with acute stroke that could be incorporated into a stroke center model were selected. CONSENSUS PROCESS: Articles were reviewed initially by 1 author (M.J.A.). Members of the BAC reviewed each recommendation in the context of current practice parameters, with special attention to improving the delivery of care to patients with acute stroke, cost-effectiveness, and logistical issues related to the establishment of primary stroke centers. Consensus was reached among all BAC participants before an element was added to the list of recommendations. CONCLUSIONS: Randomized clinical trials and observational studies suggest that several elements of a stroke center would improve patient care and outcomes. Key elements of primary stroke centers include acute stroke teams, stroke units, written care protocols, and an integrated emergency response system. Important support services include availability and interpretation of computed tomography scans 24 hours everyday and rapid laboratory testing. Administrative support, strong leadership, and continuing education are also important elements for stroke centers. Adoption of these recommendations may increase the use of appropriate diagnostic and therapeutic modalities and reduce peristroke complications. The establishment of primary stroke centers has the potential to improve the care of patients with stroke. JAMA. 2000.

New antiepileptic drugs and preparations.

Epilepsy affects 1.2% to 4.4% of the general population. Given the clinical profile of the newer antiepileptic agents, it is likely their usage will increase in the coming years, thus increasing the emergency physician's exposure to these medications and their side effects. Several of these side effects can have high morbidity, such as the aplastic anemia and hepatotoxicity caused by felbamate, and the Stevens-Johnson syndrome associated with lamotrigine. Overdoses of these medications also could increase, as will our knowledge of recognizing and managing them. The clinical spectrum of the newer medications is the treatment of partial seizures. None of the newer medications can be orally loaded nor are they available in an i.v. preparation. Serum drug levels are not available in most institutions and are not routinely measured in the ED. The new preparations of phenytoin, diazepam, and valporic acid add increased efficiency in drug administration, providing a new method for prehospital treatment of seizures and a more tolerable means of administration in the ED.

Emergency medicine at the Mount Sinai School of Medicine.

Emergency medicine became the twenty-third specialty by the American Board of Medical Examiners in 1979. Emergency physicians are specialists in the stabilization and resuscitation of medical and surgical emergencies in patients of all ages; they are experts in triage and in prioritization of resources. Emergency physicians provide the "safety net" for the American health care system, and they are the facilitators between the community and health care systems, and between primary care physicians and specialists. The emergency department is an ideal environment in which to teach the assessment and management of patients presenting with undifferentiated processes. Emergency physicians possess a unique set of clinical and research skills that have made them valuable members of the medical school academic community. Presented is a historical perspective on the specialty of emergency medicine and its evolving role at the Mount Sinai School of Medicine. Included are discussions on innovations in teaching developed by the emergency medicine faculty, including applications of computer-assisted instruction and the Internet.

A case of seizure-related bradycardia and asystole.

Cardiac arrhythmias are frequently seen with epileptic seizures and their occurrence has been proposed as a possible cause for sudden unexpected death in patients with epilepsy. Reported is a case of a 32-year-old man who presented to the emergency department (ED) following a generalized tonic-clonic seizure and subsequently developed sinus bradycardia and asystole following a second, witnessed tonic-clonic event. This case illustrates the potential for life-threatening cardiac arrhythmias in patients with seizures. The importance of hemodynamic monitoring in seizure patients while they are in the ED is emphasized.

Hyperkalemic ascending paralysis.

Hyperkalemia is a life-threatening electrolyte disturbance. The clinical presentation is most commonly related to its effects on cardiac conductivity and contractility, although weakness and respiratory compromise may occur. We describe what we believe to be the first reported case of life-threatening hyperkalemia presenting as an ascending paralysis which was associated with standard-dose trimethoprim-sulfamethoxazole therapy. The patient had mild, underlying renal disease which predisposed him to develop hyperkalemia. This case underscores the need to use caution in prescribing trimethoprim to such patients.

The evaluation and treatment of seizures in the emergency department.

One to two percent of visits to the emergency department are due to seizures. These patients may require aggressive stabilization and resuscitation and concurrent implementation of diagnostic testing, monitoring, and pharmacologic interventions. Seizures are usually a manifestation of an underlying pathology which requires thorough evaluation, including a careful history, physical examination, laboratory work-up, and electroencephalographic and neuroimaging studies as dictated by clinical suspicion. The evaluation and treatment of seizures in the emergency department must be comprehensive, including giving consideration to the patient's medical and social resources.

Management of life-threatening asthma in the emergency department.

Acute asthma exacerbations are frequent presentations to the emergency department. Those patients who deteriorate despite nebulized beta-agonist therapy and intravenous steroids are experiencing a life-threatening event. They pose a significant management challenge to the emergency physician. This review describes the pharmacologic options and techniques for mechanical ventilation which are available in resuscitating these patients.

Poisoning and overdose.

The differential diagnosis of all patients with altered mental status must include drug toxicity. In particular, intentional or unintentional overdosing and/or poisoning are common emergency department presenting complaints. A comprehensive approach to managing these patients must incorporate aggressive information gathering, a careful physical examination looking for toxic syndromes, and diagnostic testing. Proper decontamination is the key to effective management, as is the use of specific antidotes when indicated.

Spells. Differential diagnosis and management strategies.

In summary, when approaching the patient who has had a spell of unknown cause, the most important differentiation to make is between a syncopal episode and a seizure. The history and physical examination will provide the diagnosis in approximately 85% of cases. Once the physician has some idea of which path to pursue, it is important to order the tests in a directed fashion tailored to the patient's presentation. A shotgun approach is neither warranted nor beneficial and is best avoided when possible. Some patients will remain without a diagnosis despite a complete workup, thus it is important for the emergency physician to rule out the life-threatening possibilities and to arrange the appropriate long-term follow-up for the patient with their primary care provider.

Spinal cord syndromes.

In summary, a working knowledge of the spinal cord's anatomy is critical in understanding the various presentations of the spinal cord syndromes. A careful history and physical, including a systematic neurologic examination, will direct the diagnostic work-up. There are a number of disorders that may affect the spine which are slowly progressive and do not necessarily require an emergent evaluation. However, patients with spinal cord trauma and spinal cord metastatic lesions are at risk for rapid and progressive deterioration. These patients require high priorization in care because morbidity and mortality may be significantly impacted by rapid diagnosis and initiation of therapeutic interventions.

Medical emergencies in commercial air travel.

There are physiologic and logistic concerns involved in caring for patients with inflight emergencies. This article presents the physiologic changes that occur at altitude, the types of medical problems that can be encountered, and management strategies. An overview is also presented of the medical training of flight attendants and the medical equipment that is available on commercial aircraft.

Loss of vision.

Assessment of the patient with vision loss includes measurement of visual acuity, examination of the pupil, a finger-counting confrontation field examination, and an ophthalmoscopic examination. Opticokinetic testing is useful when functional blindness is being considered. A scheme is presented to use these findings to arrive at the anatomic level of this dysfunction. A differential diagnosis can then be generated. Some specific disorders causing vision loss are presented by anatomic location.