The use of antiemetics is a controversial topic in treatment of pediatric gastroenteritis. Although not recommended by the American Academy of Pediatrics, antiemetics are commonly prescribed by physicians. A review of the literature shows side effects of promethazine, prochlorperazine, and metoclopramide are common and potentially dangerous. Ondansetron has recently been studied as an adjunct to oral rehydration therapy in treatment of acute gastroenteritis with mild to moderate dehydration. Although studies are limited, early research suggests the medication is safe when used in a single dose and can be effective to prevent vomiting, the need for intravenous fluids, and hospital admission.

Study Objective: Despite causing significant morbidity throughout the mountainous regions of the world, the pathophysiology of acute mountain sickness (AMS) remains poorly understood. This study aims to improve the understanding of altitude illness by determining if vascular endothelial growth factor (VEGF) plays a role in the development of AMS. The purpose of this study was to determine if elevated plasma VEGF correlates with increased symptoms of AMS at high altitude. Patients and Methods: This is a prospective study of a cohort of healthy climbers on Denali (Mount McKinley) in Alaska at 14, 200 feet. Baseline demographics, medications, rates of ascent, and AMS scores were recorded. Pulse oximetry measurements and venous blood samples were obtained. Comparisons were made between mountaineers with and without AMS. Results: Seventy-two climbers were approached for participation in the study; 21 (29%) refused. Of the 51 climbers participating in the study, 14 subjects (27.5%) had symptoms of AMS and 37 subjects (72.5%) were free of symptoms of AMS. Plasma VEGF levels were 79.14 pg/dl (SD: 121.44) and 57.57pg/dl (SD: 102.71) in the AMS and non-AMS groups, respectively. These results were nonsignificant. Similarly, comparison of sex, age, rate of ascent, pulse oximetry values, or history of altitude illness did not reveal significant differences between the AMS and non-AMS groups. Conclusion: This study does not provide evidence in support of the theory that plasma VEGF correlates with symptoms of AMS.

Background: It is unclear whether local anesthetic eye drops can be safely used for the topical anesthesia of patients with minor corneal injury who are discharged from the emergency department (ED). Objectives: To assess whether topical 0.4% amethocaine self-administered to a maximum recommended frequency of once every hour for 36-48 h is safe in the management of uncomplicated corneal injury in patients discharged from the ED. Patients and Methods: A pilot randomized double-blinded trial comparing topical 0.4% amethocaine with topical normal saline. Results: Forty-seven subjects were recruited, with 22 randomized to receive amethocaine and 25 to receive placebo (normal saline) . Baseline characteristics, including corneal injury type, were similar in both groups. There were no significant functional or clinical adverse sequelae in the majority of enrolled patients who could be contacted at 2 weeks (17/22 for amethocaine and 21/25 for placebo). Follow-up for the primary study outcome was suboptimal, with only 7/22 from the amethocaine group and 9/25 from the saline group presenting for 36-48 h review; there was a statistically nonsignificant trend for persistence of the corneal defect in the amethocaine group as compared with the saline group (2/7 and 1/9, respectively). Conclusion: Compared with saline drops, amethocaine eye drops are not definitely safe but they are effective for topical analgesia in minor corneal injury. Until further definitive studies, topical nonsteroidal agents or long-lasting artificial tears may be preferred for the topical analgesia of minor corneal injury. Return for corneal re-evaluation will necessarily remain suboptimal in an otherwise self-limiting condition, leading to a bias even if study recruitment is good.

Background: To examine the on-call emergency workload of a general surgical team at a tertiary care teaching hospital to guide planning and provision of better surgical services. Patients and Methods: During six months period from August to January 2007; all emergency calls attended by general surgical team of Surgical Unit II in Accident and Emergency department (A and E) and in other units of Civil, Hospital Karachi, Pakistan were prospectively recorded. Data recorded includes timing of call, diagnosis, operation performed and outcome apart from demography. Results: Total 456 patients (326 males and 130 females) were attended by on-call general surgery team during 30 emergency days. Most of the calls, 191 (41.9%) were received from 8 am to 5 pm. 224 (49.1%) calls were of abdominal pain, with acute appendicitis being the most common specific pathology in 41 (9.0%) patients. Total 73 (16.0%) calls were received for trauma. Total 131 (28.7%) patients were admitted in the surgical unit for urgent operation or observation while 212 (46.5%) patients were discharged from A and E. 92 (20.1%) patients were referred to other units with medical referral accounts for 45 (9.8%) patients. Total 104 (22.8%) emergency surgeries were done and the most common procedure performed was appendicectomy in 34 (32.7%) patients. Conclusion: Major workload of on-call surgical emergency team is dealing with the acute conditions of abdomen. However, significant proportion of patients are suffering from other conditions including trauma that require a holistic approach to care and a wide range of skills and experience. These results have important implications in future healthcare planning and for the better training of general surgical residents.

Background: The incidence of acute renal failure (ARF) in the hospital setting is increasing. It portends excessive morbidity and mortality and a considerable burden on hospital resources. Extracorporeal therapies show promise in the management of patients with shock and ARF. It is said that the potential of such therapy goes beyond just providing renal support. The aim of our study was to analyze the clinical setting and outcomes of critically ill ARF patients managed with continuous renal replacement therapy (CRRT). Patients and Methods: Ours was a retrospective study of 50 patients treated between January 2004 and November 2005. These 50 patients were in clinical shock and had concomitant ARF. All of these patients underwent CVVHDF (continuous veno-venous hemodiafiltration) in the intensive care unit. For the purpose of this study, shock was defined as systolic BP < 100 mm Hg in spite of administration of one or more inotropic agents. SOFA (Sequential Organ Failure Assessment) score before initiation of dialysis support was recorded in all cases. CVVHDF was performed using the Diapact^® (Braun) CRRT machine. The vascular access used was as follows: femoral in 32, internal jugular in 8, arteriovenous fistula (AVF) in 4, and subclavian in 6 patients. We used 0.9% or 0.45% (half-normal) saline as a prefilter replacement, with addition of 10% calcium gluconate, magnesium sulphate, sodium bicarbonate, and potassium chloride in separate units, while maintaining careful monitoring of electrolytes. Anticoagulation of the extracorporeal circuit was achieved with systemic heparin in 26 patients; frequent saline flushes were used in the other 24 patients. Results: Of the 50 patients studied, 29 were males and 21 females (1.4:1). The average age was 52.88 years (range: 20-75 years). Causes of ARF included sepsis in 24 (48%), hemodynamically mediated renal failure (HMRF) in 18 (36%), and acute over chronic kidney disease in 8 (16%) patients. The overall mortality was 74%. The average SOFA score was 14.31. The variables influencing mortality on multivariate analysis were: age [odds ratio (OR):1.65; 95% CI: 1.35 to 1.92; P = 0.04], serum creatinine (OR:1.68; 95% CI: 1.44 to 1.86; P = 0.03), and serum bicarbonate (OR: 0.76; 95% CI: 0.55 to 0.94; P = 0.01). On univariate analysis the SOFA score was found to be a useful predictor of mortality. Conclusions: Despite advances in treating critically ill patients with newer extracorporeal therapies, mortality is dismally high. Multiorgan dysfunction adversely affects outcome of CRRT. Older age, level of azotemia, and severity of metabolic acidosis are important predictors of adverse outcome.

Background: Brief intervention (BI) to reduce hazardous drinking and negative consequences such as injury has been effective when given in the emergency department (ED). The effectiveness and effect of BI has varied between injured and uninjured ED patients. This study compares injured and uninjured ED patients who admit to alcohol and marijuana use to determine their need and their readiness for BI. Patients and Methods: Participants volunteered to enter a randomized controlled trial of BI to reduce hazardous alcohol and marijuana use. Adult ED patients who had had alcohol in the last month and smoked marijuana in the last year were recruited. Those patients who were admitted to hospital, were under police custody, or were seeking treatment for substance use or psychiatric disorder were excluded. Research assistants interviewed participants using a validated questionnaire. Data were analyzed using SAS (version 9.1). Binominal tests of proportions, t-test analyses, and transformations were conducted as appropriate. Results: Injured (n = 249) and uninjured (n = 266) study participants reported very high, statistically equivalent (P > 0.05), rates of binge drinking (4-5 days/month), marijuana use (13 days/month), driving under the influence of marijuana or alcohol (>49% in the last 3 months), injury (>83% in the last year), and other negative consequences (>64% in the last 3 months) prior to their ED visit. These behaviors and the consequences demonstrate a need for change. Both injured and uninjured subjects were ready to change (>56%) and confident they could change (>91%) alcohol and marijuana use. Discussion: ED patients who admit to alcohol and marijuana use also use other hazardous substances and participate in high-risk behaviors. In both injured and uninjured patients who admit using alcohol and marijuana, the ED visit is an opportunity to deliver BI to reduce alcohol and marijuana use and associated risk behaviors and the subsequent injury and negative consequences. Given their risk behaviors and experience of negative consequences, members of both injured and uninjured groups have an equal need for BI. Fortunately, in both groups, a high number of members express motivation to change.

Fat emboli occur in all patients with long-bone fractures, but only few patients develop systemic dysfunction, particularly the triad of skin, brain, and lung dysfunction known as the fat embolism syndrome (FES). Here we review the FES literature under different subheadings. The incidence of FES varies from 1-29%. The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult. The other causes for the above-mentioned organ dysfunction have to be excluded. The clinical criteria along with imaging studies help in diagnosis. FES can be detected early by continuous pulse oximetry in high-risk patients. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.

Cardiopulmonary arrest in pregnancy is rare occurring in 1 in 30,000 pregnancies. When it does occur, it is important for a clinician to be familiar with the features peculiar to the pregnant state. Knowledge of the anatomic and physiologic changes of pregnancy is helpful in the treatment and diagnosis. Although the main focus should be on the mother, it should not be forgotten that there is another potential life at stake. Resuscitation of the mother is performed in the same manner as in any other patient, except for a few minor adjustments because of the changes of pregnancy. The specialties of obstetrics and neonatology should be involved early in the process to ensure appropriate treatment of both mother and the newborn. This article will explore the changes that occur in pregnancy and their impact on treatment. The common causes of maternal cardiac arrest will be discussed briefly.

Cardiac conduction disorders following oral ingestion of Oleander plant materials were documented earlier. Transcutaneous absorption of yellow oleander (Thevetia peruviana) leaf extract applied over non intact skin (raw wound) resulting in reversible cardiac conduction disorder observed in four healthy males who were free from any other systemic or electrolyte or metabolic disorders or exposure to pesticide or toxins is reported for the first time. Their hematological, biochemical, clinical, and echocardiogram status were within normal limits and free of any abnormalities. One among the four, presented for weakness and breathlessness (class II). He had bradycardia with Mobitz II block and hypotension without any other demonstrable localizing signs. The other three were identified in the community and without any symptoms. However, their ECG revealed bradycardia with Mobitz I block in two and complete heart block in the other. All of the four recovered well without any untoward events. Hence, it is suggested that physicians and practitioners have to elicit history and route of administration of unconventional therapy, whenever they are confronted with clinical challenges and during medical emergencies before embarking final decision.

The acute abdomen in pregnancy is a surgical emergency. Ectopic pregnancy and appendicitis are two causes of acute abdomen in pregnancy. Difficulties in correctly identifying the cause of the pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. The case presented here underlies the pathogenesis of the simultaneous existence of these two conditions in a patient.

Presented is a case of cavernous sinus thrombosis in a young female with fatal outcome. There were not any septic focus, no history of head trauma, no relation with pregnancy. Computed tomography scan of brain showed chronic subdural hematoma. An attempt is made to correlate the aetiopathology with the clinical features of this rare case presentation.

Airway management in the operating room is the responsibility of anesthesiologists, although a variety of personnel may be responsible for airway management outside the operating room. Emergency department physicians are prominently involved in airway management in the emergency room both independently and with anesthesiologists. Airway management in trauma patients remains the domain of anesthesiologists. An 18-year old male patient was brought to our emergency room after an alleged history of suicidal attempt with gunshot under the chin. He was scheduled to undergo emergency tracheotomy, debridement, and closure of facial laceration under general anaesthesia, presenting a challenge for. He had to undergo emergency tracheotomy, debridement, and closure of facial lacerations under general anesthesia. The injuries made the patient's airway management a complex issue. We present the use of the light wand to manage the difficult airway of this patient with complex facial trauma.

Emergency cricothyrotomy is a technique used to secure an otherwise compromised or inaccessible airway and has been recommended for use in the battlefield under certain circumstances. This case reports an acute complication of emergency cricothyrotomy. An Iraqi soldier, injured in an improvised explosive device blast received an emergency battlefield cricothyrotomy. At the Combat Support Hospital, the patient became more difficult to ventilate and was taken to the operating room for tracheostomy. The cricothyrotomy tube was found to be occluded with blood.