Obstetric infections

Maternal infections are unique because of their implications for the outcome of pregnancy. Bacterial infections that can be favorably influenced by prompt diagnosis and preventive management include urinary tract infections and chorioamnionitis. However, viral infections such as genital herpes and cytomegalovirus, and the parasitic disease toxoplasmosis, require specialized forms of testing and a complicated management plan. Altered physiological and immunological states during pregnancy are important in understanding the pathophysiology of maternal infections.     

Obstetric cholestasis

The field of orthopaedic surgery has changed rapidly in the last ten years, increasing the demand for a readily available supply of allograft. Historically, bone was first grafted in 1668. The first clinical allograft was performed in 1820 by Phillips von Walter who reconstructed part of a skull. Clinical use of allograft has developed steadily during this century, making it now an essential requirement in orthopaedic surgery. Nationally, there is a shortage of available allograft for orthopaedic procedures. Allograft bone can be used in spinal fusion, filling of bone cysts, non-union of fractures and, most commonly, in revision joint replacements. In the last twenty years joint replacement surgery has become common practice and the number of patients requiring revision joint surgery has also increased. This expansion will continue owing to the growing demands made on our health service by our increasingly elderly population. We can expect an increase in demand for allograft.     

Vascular emergencies

This article reviews the initial assessment and emergent management of several common as well as uncommon vascular emergencies. Aortic dissection, aneurysms, and arterial occlusive disease are familiar but challenging clinical entities. Less frequently encountered conditions are also discussed including an aortic enteric fistula, mesenteric venous thrombosis, phlegmasia alba dolens, and subclavian vein thrombosis.     

Urological emergencies

Every general practitioner has to deal with urologic emergencies. The most frequent illnesses are urinary retention, acute scrotum, priapism, macrohematuria, nephritic colic, obstructive pyelonephritis and pyonephrosis. Whereas urinary retention, as well as acute ureteric stone colic must generally be treated by the practitioner, the urologist must often be consulted in case of an acute scrotum or for priapism. Testicular torsion is one situation, where surgical treatment needs to be performed within 6 hours. Of utmost importance is his timely assistance with the obstructive pyelonephritis and pyonephrosis. These are initially often not recognized, especially because the first ultrasound examination of the intrarenal pyelone may not show a dilatation of the collecting system despite obstruction. If the adequate treatment with drainage and antibiotics is applied too late, this can result in serious and potentially lethal consequences.     

Splenic emergencies

Of medical and surgical emergencies in the pediatric abdomen, those involving the spleen are relatively less common than other abdominal organs, though equally important to recognize. A more sophisticated clinical understanding of the important role of the spleen in immunocompetence has developed in parallel with advancements in imaging. A healthy respect for the preservation of splenic tissue has emerged, altering traditional surgical management of splenic emergencies. Non-invasive imaging has come to play a vital role in depicting acute abnormalities and in determining the need for conservative, interventional, or surgical management.     

Diving-related emergencies

The proliferation of sport or recreational divers over the last several decades has resulted in significant increases in the number of patients treated for diving-related emergencies. The treatment of these individuals is no longer confined to a small group of physicians with special training or experience. Rather, community emergency physicians and physicians engaged in the practice of travel medicine are increasingly called on to treat such patients. This article discusses general physical principles relating to diving medicine and common presentations and treatment of diving-related emergencies.     

Hysterical emergencies

Most probably common in emergency departments, but still not well studied in this context, the disorders formerly called "hysteria" are now included in the group "Somatization, undifferentiated somatoform, conversion and dissociative disorders" (SSCD disorders) DSM IV. Their common presentation is that of idiopathic somatic symptoms linked with mental disorders. In the emergency department these symptoms confront physicians who generally do not have extensive psychiatric training. The symptoms occur, and disappear, undetermined by the patients, who are genuinely ill and not malingering. Aside from the somatisation disorder, which by definition is chronic, invalidating and rare, the other disorders (SCD) can: be contingent on the picture of another acute, easily recognisable mental disorder; or, on the other hand, be highly reactional and transient; or constitute the "somatic presentation" of an anxious disorder, the panic attack, well known in somatic emergencies. Management is based on diagnostic considerations and by the difficulties of the patient to accept a psychic cause of the symptoms whereas he is experiencing an organic disorder. The possibilities of discussing such psychogenesis in the context of the emergency department are slight, and the best course is often to adopt a pragmatic and prudent medical approach. An essential point is respect of the patient and his ideas. The legal provision, which already exists, for the presence of psychiatrists in emergency departments should lead to physician-psychiatrist cooperation that would be beneficial for these patients.     

Hematologic emergencies

The most common life-threatening hematologic emergencies include hemorrhage and severe anemia. Successful treatment of these conditions depends on the emergency veterinarian having a thorough understanding of the possible etiologies of these conditions, and a systematic approach to diagnosis and therapy. Use of blood component therapy can be a life-saving technique in these patients. The goal of this article is to familiarize the emergency veterinarian with a systematic approach to the diagnosis and treatment of hematologic emergencies.     

Environmental emergencies

This article reviews the pearls and pitfalls of high-altitude sickness, decompression sickness, and barotrauma; new findings relevant to the near-drowning patient; continued controversies on hyperbaric oxygen for carbon monoxide poisoning; pitfalls in hypothermia management; and updates on the management of venomous snakebites.