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BACKGROUND: Clopidogrel is an adenosine diphosphate receptor antagonist. The risk of intracranial hemorrhage following minor head trauma in patients with pre-injury use of clopidogrel has not been fully determined. METHODS: This case-controlled study examined the effects of pre-injury use of clopidogrel in adult (age 14 years and older) patients with minor head trauma. RESULTS: During the study period, 1660 patients head computed tomography scans were performed in the emergency department, of which 658 met inclusion criteria. Intracranial hemorrhage was noted in 30% of patients on clopidogrel, compared with 2.2% of those patients without pre-injury use of clopidogrel. After performing a logistic regression analysis for confounders, the pre-injury use of clopidogrel was significantly associated with intracranial hemorrhage in this study population (OR 16.7; 95% CI 1.71-162.7). CONCLUSION: The use of clopidogrel is associated with a significantly increased risk of developing intracranial hemorrhage following minor trauma.
Assuntos
Traumatismos Craniocerebrais/complicações , Hemorragia Intracraniana Traumática/induzido quimicamente , Inibidores da Agregação Plaquetária/efeitos adversos , Ticlopidina/análogos & derivados , Adulto , Estudos de Casos e Controles , Clopidogrel , Traumatismos Craniocerebrais/diagnóstico por imagem , Feminino , Humanos , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Neuroimagem , Fatores de Risco , Ticlopidina/efeitos adversos , Tomografia Computadorizada por Raios XRESUMO
Bloodstream infections are now ranked as the 10th leading cause of death in the United States. Given the severity of bacteremia, physicians routinely order multiple sets of blood cultures in the emergency department. This is a retrospective chart review on 1124 patients admitted to the hospital for suspected bacteremia during calendar year 2004. The aims of the present investigation were to investigate the overall utility of blood cultures by the admitting services and to identify patient factors that might influence culture yield. Data were collected regarding patient demographics, comorbidities, vital signs, laboratory results, antibiotic use, blood culture results, and notation of blood culture results by admitting physicians. Increased age, elevated heart rate, use of chemotherapy, decreased sodium, and increased blood urea nitrogen significantly increased the likelihood of yielding a positive blood culture in our patient population. Culture results were noted in 517 patient charts by the primary medical team (46.0%) and were adjusted in 223 patients (43.3%). Of 1124 cultures, 10.3% were positive in at least 1 bottle for a pathogenic organism (true positive), and 6.3% were contaminants (false positive). In conclusion, cultures must be followed closely by the admitting physician after being obtained. Our data emphasize that blood cultures are currently not well used by the admitting physicians and that measures need to be taken to improve the overall utility of blood culture data by the admitting physician.
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Bacteriemia/sangue , Coleta de Amostras Sanguíneas/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Bacteriemia/diagnóstico , Bacteriemia/tratamento farmacológico , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
PURPOSE: We sought to determine whether dilation of the optic nerve sheath diameter (ONSD), as detected at the bedside by emergency ultrasound (US), could reliably correlate with patient blood pressure and whether there was a blood pressure cutoff point where you would start to see abnormal dilation in the ONSD. METHODS: This was a single-blinded, prospective, observational trial from September 2010 to April 2011. One hundred fifty patients presenting to the emergency department were enrolled. There were 3 arms to the study with 50 patients in each arm: (1) ONSD in normotensive/asymptomatic patients; (2) ONSD in hypertensive/asymptomatic patients; and (3) ONSD in hypertensive/symptomatic patients. Ocular US was conducted on all subjects. RESULTS: Neither the number of symptoms nor the type of symptom present in the hypertensive/symptomatic group was able to significantly predict the average ONSD before treatment (P = .818 and .288, respectively). There was a significant correlation between both systolic blood pressure (SBP) and diastolic blood pressure (DBP) with the ONSD in all hypertensive patients. The best SBP and DBP cutoff point for abnormal ONSD was 166/82 mm Hg. Decrease in ONSD observed after blood pressure treatment was not statistically significant (P = .073). CONCLUSIONS: In conclusion, our study shows that practitioners can use bedside ocular US and a blood pressure cutoff point to help predict whether patients require more aggressive management of their symptomatic hypertension. Knowing the SBP and DBP readings that lead to increased ONSD and increased intracranial pressure can help guide management and treatment decisions at the bedside.
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Hipertensão/diagnóstico por imagem , Hipertensão Intracraniana/diagnóstico por imagem , Nervo Óptico/diagnóstico por imagem , Idoso , Pressão Sanguínea , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Prospectivos , Método Simples-Cego , UltrassonografiaRESUMO
OBJECTIVE: The primary purpose of this study was to investigate the overall accuracy of bedside extremity tendon ultrasound performed by emergency physicians in the emergency department. We also sought to investigate whether or not bedside tendon ultrasonography can be used to expedite the diagnosis and discharge planning in patients with suspected tendon injuries. METHODS: This was a prospective study conducted at 2 academic level 1 trauma centers. Thirty-four patients were enrolled and underwent a comprehensive physical examination of the injured extremity, followed by a bedside ultrasound evaluation to look for tendon disruption. Results of the tendon ultrasound were compared against the findings seen during wound exploration in the emergency department, wound exploration in the operating room, or results from an extremity magnetic resonance imaging (MRI). RESULTS: There were 6 finger injuries, 11 hand injuries, 6 arm injuries, 6 forearm injuries, and 5 lower extremity injuries. Of the 34 total patients, 4 patients had partial tendon injuries, 9 suffered from 100% tendon laceration or rupture, and 21 had no tendon injury noted on exploration or MRI. Bedside ultrasound had a sensitivity, specificity, and accuracy of 100%, 95%, and 97%, respectively. Physical examination had a sensitivity, specificity, and accuracy of 100%, 76%, and 85%, respectively. Average time to bedside ultrasound was 46.3 minutes compared with 138.6 minutes for wound irrigation and exploration, MRI, or surgery consultation. CONCLUSION: Bedside ultrasound is more sensitive and specific than physical examination for detecting tendon lacerations, and takes less time to perform than traditional wound exploration techniques or MRI.
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Sistemas Automatizados de Assistência Junto ao Leito , Traumatismos dos Tendões/diagnóstico por imagem , Traumatismos do Braço/diagnóstico , Traumatismos do Braço/diagnóstico por imagem , Traumatismos da Mão/diagnóstico , Traumatismos da Mão/diagnóstico por imagem , Humanos , Traumatismos da Perna/diagnóstico , Traumatismos da Perna/diagnóstico por imagem , Imageamento por Ressonância Magnética , Exame Físico , Estudos Prospectivos , Sensibilidade e Especificidade , Traumatismos dos Tendões/diagnóstico , Fatores de Tempo , Centros de Traumatologia/estatística & dados numéricos , UltrassonografiaRESUMO
Between 1972 and 1999, the Orthopedic Oncology Service treated 150 patients with resection and allograft transplantation of the proximal femur. Of the group, 121 patients had malignant tumors of the proximal femur and 29 had benign disorders. Four types of allografts were used: osteoarticular (46 patients), allograft-prosthesis (73), intercalary (20), and allograft-arthrodesis (5). Only 16% of the patients died of disease and 3% required amputation. The overall success rate for the series was 77% with the best results for the allograft prosthetic (82%) and intercalary procedures (87%). Graft infection (15 patients), allograft fracture (26 patients), and local recurrence (11 patients) most markedly affected outcome. With the exception of deaths of disease, no significant outcome difference occurred between the patients with malignant and benign disorders. In conclusion, allograft implantation especially for aggressive or malignant tumors of the proximal femur appears to be a competent system for therapy.
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Doenças Ósseas/cirurgia , Neoplasias Ósseas/cirurgia , Fêmur/cirurgia , Fêmur/transplante , Articulação do Quadril/cirurgia , Adolescente , Adulto , Idoso , Doenças Ósseas/mortalidade , Neoplasias Ósseas/mortalidade , Criança , Pré-Escolar , Feminino , Displasia Fibrosa Óssea/mortalidade , Displasia Fibrosa Óssea/cirurgia , Doença de Gaucher/mortalidade , Doença de Gaucher/cirurgia , Articulação do Quadril/diagnóstico por imagem , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Osteocondroma/mortalidade , Osteocondroma/cirurgia , Osteonecrose/mortalidade , Osteonecrose/cirurgia , Prognóstico , Radiografia , Estudos Retrospectivos , Transplante Homólogo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Cavernous malformations prevalence ranges from 0.4 to 0.6% and accounts for 5-15% of all central nervous system vascular malformations. Pineal cavernomas constitute <1% of all locations published in the literature, with a total of 26 cases reported, only 5 regarding the pediatric population until 2020. Overall annual hemorrhage rate is 2.4%. Symptoms are often due to hydrocephalus and intracranial hypertension. CASE DESCRIPTION: We report a case of a 5-year-old child with visual disturbances, headache, and progressive neurologic deterioration. MR showed a lesion in the pineal region and triventricular hydrocephalus. She was submitted to endoscopic third ventriculostomy and total excision of the lesion by the infratentorial supracerebellar approach a few days later. Histopathological examination confirmed a pineal cavernous malformation. The patient returned to her normal life without any neurologic deficit and a normal development. CONCLUSION: The ideal treatment is primary lesion removal; however, due to the infrequency and because it is a curable lesion, studies seeking to deepen the knowledge of this disease are considered relevant.
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BACKGROUND: Melanoma is the third most common primary tumor to metastasize to the central nervous system (CNS). However, primary CNS melanoma is very rare, and primary intramedullary melanoma is even less frequently encountered, with only 27 cases published in the literature. There are no pathognomonic imaging characteristics, therefore, the diagnosis must be confirmed immunohistologically and the preferred treatment is the gross total resection. CASE DESCRIPTION: A 68-year-old male presented with low back pain of 2 months duration, and 1 week of urinary retention/anal sphincter incontinence. The neurologic examination revealed bilateral paraparesis (3/5 level) with bilateral Babinski signs, and a T10-T11 pin level. The lumbar CT-Scan showed a hyperdense intramedullary tumor arising from the conus medullaris. The patient underwent a D12-L2 laminectomy with myelotomy for gross-total tumor resection. Postoperatively, he regained motor function but the urinary incontinence remained unchanged. The diagnosis of a primary malignant melanoma was confirmed both histopathologically and immunohistochemically (e.g., staining revealed positive immunoreactivity for S100 protein and Melan A). CONCLUSIONS: Primary intramedullary spinal melanoma is very rare, and the diagnosis must be biopsy/operatively confirmed. Whether gross total resection is feasible depends on the extent of tumor infiltration of the cord/ adherence as well as the potential for clinical deterioration with overly aggressive removal.
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Many ocular emergencies are difficult to diagnose in the emergency setting with conventional physical examination tools. Additionally, persistent efforts to re-examine the eye may be deleterious to a patient's overall condition. Ultrasound is an important tool because it affords physicians a rapid, portable, accurate, and dynamic tool for evaluation of a variety of ocular and orbital diseases. The importance of understanding orbital anatomy, with attention to the firm attachment points of the various layers of the eye, cannot be understated. This article describes the relevant eye anatomy, delves into the ultrasound technique, and illustrates a variety of orbital pathologies detectable by bedside ultrasound.
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Emergências , Oftalmopatias/diagnóstico por imagem , Traumatismos Oculares/diagnóstico por imagem , Ultrassonografia/métodos , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia/instrumentaçãoRESUMO
Use of bedside ultrasound to guide simple procedures increases safety by allowing real-time visualization of patient anatomy. This article discusses ultrasound guidance for basic procedures including peripheral and central intravenous access, arterial access, suprapubic aspiration, abscess incision and drainage, foreign body identification, and joint arthrocentesis. It reviews the indications and complications of the procedure, advantages of ultrasound guidance, anatomy, and procedural technique.
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Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia de Intervenção/métodos , Abscesso/diagnóstico por imagem , Abscesso/cirurgia , Cateterismo Venoso Central , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/cirurgia , Humanos , Artropatias/diagnóstico por imagem , Artropatias/cirurgia , Ultrassonografia de Intervenção/instrumentação , Procedimentos Cirúrgicos VascularesRESUMO
Ultrasound guidance has become the standard of care for many bedside procedures, owing to its portability, ease of use, and significant reduction in complications. This article serves as an introduction to the use of ultrasonography in several advanced procedures, including pericardiocentesis, thoracentesis, paracentesis, lumbar puncture, regional anesthesia, and peritonsillar abscess drainage.
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Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia de Intervenção/métodos , Anestesia por Condução , Drenagem , Humanos , Paracentese , Pericardiocentese , Abscesso Peritonsilar/diagnóstico por imagem , Abscesso Peritonsilar/cirurgia , Punção Espinal , Toracostomia , Ultrassonografia de Intervenção/instrumentaçãoRESUMO
Numerous medications and illicit drugs can predispose an individual to heat illness, primarily by altering thermoregulation by either increasing endogenous heat production or impairing heat dissipation. This study sought to determine if use of such drugs was associated with more severe illness in patients presenting with heatstroke. A case control study was conducted on adult patients (age, ≥14 years) admitted to an intensive care unit with an admitting diagnosis of heatstroke at two academic teaching hospitals in Phoenix, AZ, between 31 August 2005 through 31 July 2010. Subjects were classified as "users" if they admitted to taking a drug on a pre-defined list of drugs associated with abnormal thermal homeostasis, or if a urine test for drugs of abuse revealed the presence of an amphetamine or cocaine. Similarly, subjects who did not take such drugs were considered "non-users." Seventy-eight patients were identified, with complete medication histories available for 74 of 78 subjects. The overall prevalence of drug utilization was 41.9 % (31 of 74). The median length of stay was 3.0 days for the non-users compared with 9.0 days for "users." There was no difference between users and non-users with regard to mortality. Drugs that impair thermoregulation are frequently encountered in patients admitted for heatstroke. Patients taking such drugs may experience increased morbidity over those patients not taking such drugs.
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Anfetamina/efeitos adversos , Cocaína/efeitos adversos , Golpe de Calor/mortalidade , Drogas Ilícitas , Adulto , Idoso , Arizona/epidemiologia , Estudos de Casos e Controles , Feminino , Golpe de Calor/epidemiologia , Hospitalização , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Morbidade , Prevalência , Fatores de RiscoRESUMO
BACKGROUND: Schwannomas of the abducens nerve are extremely rare tumors. The tumor may be located within the cavernous sinus or more often at the prepontine region. However, literature research has identified only one case of isolated schwannoma of the orbit, arising from the terminal branches of the abducens nerve to the lateral rectus muscle. This is only the second report of an abducens nerve schwannoma located entirely intraconal. CASE DESCRIPTION: We report a case of an intraorbital abducens nerve schwannoma in a 42-year-old man with no signs of neurofibromatosis. The lesion resulted in progressive diplopia and focal abducens palsy. The clinical, radiologic, and pathologic features are presented. RESULTS: We point the particular aspects and discuss the possible treatments and approaches to preserve nerve function. CONCLUSIONS: Being a benign lesion, one of the goals has always been total removal. The knowledge of the correct anatomic features made us believe that the VI nerve function could be preserved. Our case is the first example of a total removal with eye abduction preserved. Because of that, we believe that it is reasonable to aim for these goals in future cases.
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Doenças do Nervo Abducente/patologia , Neoplasias dos Nervos Cranianos/patologia , Neurilemoma/patologia , Neoplasias Orbitárias/patologia , Doenças do Nervo Abducente/cirurgia , Adulto , Neoplasias dos Nervos Cranianos/cirurgia , Humanos , Masculino , Neurilemoma/cirurgia , Neoplasias Orbitárias/cirurgiaRESUMO
Adamantinoma is a rare tumour, which most often affects the tibia and produces lytic and sometimes destructive lesions, which can cause fractures. The lesions occur principally in adults and are more common in males. A small percentage of the patients develop metastases, sometimes quite late in the course. Our institution has treated 42 patients with adamantinomas since 1972 and has evaluated them by imaging studies and histology. The majority of the patients were treated by resection of the lesion and insertion of an intercalary allograft. Only three of the patients died of disease with the time until death ranging from 10 to 17 years. Recurrence occurred in only three patients and the allograft success rate in terms of function was 71% at a mean time of 10 years.