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Background Valproic acid (VPA) is increasingly used to treat a variety of medical disorders, such as seizures, psychiatric disorders, and headaches. Therefore, accidental and intentional ingestions with valproic acid are increasing. Objectives A case is presented in an adolescent with ischemic electrocardiographic changes after an acute overdose with VPA. Discussion Major features of a valproic acid overdose include respiratory depression, progressive coma, hepatotoxicity, thrombocytopenia, and hemodynamic instability. Electrocardiographic abnormalities usually consist of tachycardia and nonspecific changes. Supportive care is indicated in most overdoses and involves the monitoring and correction of electrolyte abnormalities, coagulopathies, and acid-base imbalances. Treatment may include activated charcoal, naloxone, l -carnitine, and extracorporeal detoxification. Conclusions Valproic acid overdose is a relatively rare and electrocardiographic changes usually consist of tachycardia and nonspecific changes, but ischemic changes may occur and usually transient and require only recognition.

Background: Spinal vertebral fractures are common in elderly patients, especially after a significant fall. Neck tenderness or neurologic deficits after a fall should increase the suspicion of cervical spinal fracture. Case Report: A 75-year-old woman complained of 2 weeks of gradually increasing neck and right shoulder pain after a fall. She had an X-ray study that appeared to show an unstable C6–C7 fracture. A computed tomography scan of the neck revealed no fracture and was consistent with spondylodiscitis and osteomyelitis of C6 and C7, with an adjacent epidural abscess and mild cord compression. Conclusion: It is important to consider this diagnosis in patients with a history of infective endocarditis who develop back pain, to minimize morbidity associated with this disorder.

BACKGROUND The importance of thrombolytic therapy within the first 3 hours of onset of symptoms of an acute stroke has been stressed, and in consequence, the diagnosis is most commonly made based on clinical grounds. Intracranial hemorrhage is the major life-threatening complication with the use of thrombolytic therapy. Because of the very small time window before administering thrombolytics, it is often not possible to investigate the unusual causes of a stroke that occurs most often in children. OBJECTIVE This study aimed to present the decision and risk of thrombolysis for an acute ischemic stroke in children. CASE A case of a teenager with an acute ischemic stroke who received thrombolysis and had resolution of symptoms. CONCLUSIONS Thrombolytic therapy is effective in acute ischemic strokes; however, in children, one must consider and exclude stroke mimickers and recognize that potentially life-threatening bleeding complicates the use of these medications.

Background Vertebral fractures and severe injuries to the spine cord in children are rare and account for a small proportion of all childhood injuries. Pediatric vertebral and spinal cord injuries have unique characteristics depending on their age. Young children sustain upper cervical spine injuries, which are more serious injuries and have a higher mortality rate. Older children have lower spine injuries and thoracoabdominal injuries. Objectives This study aimed to present the epidemiology and potential complications from lumbar spine fractures. Cases There were 4 cases of older children who sustained lumbar vertebral fractures. Conclusions Fractures of the lumbar spine in children, although relatively rare, are important to understand. Patterns of injury with vertebral and spinal cord injuries in children vary from those of adults. The biologic differences of children make differences in fracture patterns and alter the management necessary for successful treatment. Errors in management can have adverse effects on these injuries.

Background: Neuroblastoma is the most common extracranial solid tumor in children under the age of 5 years and, after acute lymphoblastic leukemia, is the second most prevalent malignancy in childhood. Acute urinary retention is rare in children, especially due to a neuroblastoma. Objectives: To present the potential complications of a pelvic neuroblastoma. Case report: A 9-month-old infant presented with urinary retention that had been attributed in the past to the infant's chronic constipation. She was catheterized and a large residual of urine was obtained; she was discharged home. She returned the following day with the same complaint. Plain radiographs suggested a soft tissue density in the pelvic region with no evidence of constipation. Rectal examination revealed a mass, and a computed tomography scan showed a large, solid mass. Pathological examination confirmed a pelvic neuroblastoma, which was resected. Conclusions: The most common causes of acute urinary retention are urinary tract infections, lower urinary stones, neurologic processes, trauma, and constipation. A detailed and focused history and physical examination can be very helpful in diagnosing a pathological cause of urinary retention, such as a pelvic neuroblastoma.

Hereditary angioedema is a disorder characterized by decreased levels or function of complement C1 esterase inhibitor. Symptoms in children generally consist of recurrent episodes of soft tissue swelling. On rare occasion, it can cause airway edema which may lead to airway obstruction. A case is presented of a child presenting with epiglottitis requiring intubation. Initial management of this rare complication should be directed at establishing an adequate airway and ensuring good oxygenation and ventilation. In addition, prompt administration of C1 esterase inhibitor concentrate is the most effective means of stopping progression of laryngeal edema and other forms of swelling. Commonly used agents for airway edema such as glucocorticoids, antihistamines, H1-blockers, and epinephrine tend not to be effective for reducing swelling related to hereditary angioedema.

Acetaminophen is frequently used by both physicians and parents for the relief of pain and fever in infants and children of all age groups. It has an excellent safety profile in therapeutic doses, but hepatotoxicity can develop following both intentional or unintentional overdoses. Repetitive doses of acetaminophen, usually in supratherapeutic amounts, but not always, in ill infants have been associated with hepatotoxicity. Acetaminophen toxicity may be very difficult to diagnose in young infants when suspicion for this entity is low. In addition, initial signs and symptoms are nonspecific and biochemical evidence of hepatic damage may not become evident for 24 to 36 hours. We report the case of an infant who received multiple doses of acetaminophen during an illness who developed hepatotoxicity.

Anthrax is caused by the spore-forming bacteria Bacillus anthracis. It occurs naturally, but recently has been manufactured as a biological warfare agent. This makes prophylaxis for anthrax an urgent concern and efforts are ongoing for the production of an efficient and safe vaccine. Side effects to the current anthrax vaccine are usually minor and mainly consist of local skin reactions. Occasionally an unusual complication may occur; a case of a patient with lymphocytic vasculitis temporally associated with the anthrax vaccine is reported.

BACKGROUND: Craniofacial injuries caused by television (TV) sets falling on small children are becoming a frequent event seen in emergency departments. Injuries occur primarily to the head and neck regions and range from contusions to intracerebral hemorrhage, which at times can be fatal. OBJECTIVES: Epidemiology and potential complications from TV tip-over injuries are presented. CASE: Three cases of craniofacial injuries are described from blunt trauma incurred from TV tip-over events. CONCLUSIONS: It is important to teach parents about the dangers of the new large slim TV sets and the occurrence of injuries when these are not secured properly or placed away from the reach of the child. Language: en

A 21-month-old Caucasian boy was seen at another hospital with a chief complaint of mild ecchymosis in the left infraorbital region. The parents denied any known trauma or fall. His examination did not reveal any obvious fracture and he was discharged with a presumed diagnosis of facial contusion from a fall. Three days later he presented with worsening ecchymosis and marked bilateral periorbital swelling. The child’s past medical history was unremarkable. He took no medications and had no allergies. Vital signs were normal. His facial examination showed marked swelling and periorbital ecchymosis with proptosis of both eyes. His ocular movements were decreased (Figure 1). His pupils were 4 mm and reactive. His nasal passages were obstructed with a small mass. He was lethargic but arousable. The remainder of his examination was unremarkable. The computed tomography (CT) scan of his head showed soft tissue mass in the orbital regions pushing the eyes forward and extensive bony erosions (Figures 2 and 3). He was admitted to the pediatric intensive care unit. A iopsy of the tissue revealed neuroblastoma. He was tarted on chemotherapy, but he developed neutropenic

Ataxia in children mainly occurs from post-infectious cerebellar ataxia, toxic ingestions, and labrynthitis. An unusual cause is the Miller Fisher syndrome (MFS) which is consider variant of Guillain-Barre syndrome (GBS). It is a self-limiting demyelinating disease of the peripheral nervous system characterized by the triad of ophthalmoplegia, cerebellar ataxia, and areflexia.

Management of febrile infants and children remains controversial despite the 1993 publication in Pediatrics and Annals of Emergency Medicine of practice guidelines. Our aim was to determine the management of febrile infants and children by pediatric emergency medicine (PEM) fellowship directors and emergency medicine (EM) residency directors and compare their approach with the published practice guidelines.Four case scenarios were sent to 64 PEM directors and 100 EM directors in the United States and Canada, describing four febrile, nontoxic infants and children aged 25 days (case 1), 7 weeks (case 2), 5 months (case 3), and 22 months (case 4). Respondents were asked to select which laboratory tests and radiographs they would obtain and to decide on treatment and disposition for each hypothetical case.Ninety-two percent (53/64) of PEM directors and 64% (64/100) of EM directors responded (overall response rate 74%). Compliance with the guidelines (PEM/EM) was 54%/16% for case 1, 31%/6% for case 2, 35%/19% for case 3, and 20%/11% for case 4. Only 11% of PEM and 2% of EM directors followed the guidelines for all four cases. Overall, directors performed fewer laboratory tests, ordered more chest radiographs and treated fewer patients with antibiotics than the expert panel suggested. EM directors ordered more chest radiographs (cases 1-4) and admitted more patients (case 2) than PEM directors.There is poor compliance with published practice guidelines in the management of febrile infants and children among PEM and EM directors.

Objective: this study determines the effect of prior hypothermia on the cardiovascular responses to norepinephrine (NE) after rewarming. Methods: the experiment was a 2×2 controlled design with four groups of feline animals. The two variables were the presence or absence of previous cooling, and the use or non-use of NE after rewarming. During the ‘cooling’ phase, animals were either cooled using an external arterial–venous femoral shunt to 30°C or maintained at 37°C. After ‘rewarming’ animals were stratified to receive either NE at rates to deliver 0.2, 1.0 or 5 μg/kg per h or normal saline infusions. Animals were instrumented to measure mean arterial pressure (MAP) and cardiac output (CO) and systemic vascular resistance (SVR) was calculated. Results: there were no differences between groups at baseline and low dose NE (0.2 μg/kg per min). At 1.0 μg/kg per min, NE caused a significant increase in CO (P

Abdominal pain is a common complaint in children presenting to the emergency department. Patients with systemic lupus erythematosus (SLE) are at increased risk of infection, bowel necrosis and perforation, especially if they are taking nonsteroidal anti-inflammatory drugs, corticosteroids or immunosuppresive agents, which may mask the signs and symptoms of the underlying condition, hence delay diagnosis and treatment. This article presents the case of an ado- lescent girl whose abdominal pain was related to cardiac tamponade and provides an overview of the cardiac and gastrointestinal manifestations of SLE. RESUME : La douleur abdominale est un symptome couramment rencontre chez les enfants recus a l'urgence. Les patients atteints de lupus erythemateux aigu dissemine (LEAD) courent un risque plus grand d'infection, de necrose intestinale et de perforation, surtout s'ils recoivent des anti- inflammatoires non steroidiens, des corticosteroides ou des immunosuppresseurs qui peuvent mas- quer les signes et symptomes de la condition sous-jacente, et par le fait meme, retarder le diag- nostic et le traitement. Le present article decrit le cas d'une adolescente dont la douleur abdomi- nale etait liee a une tamponnade cardiaque et offre un apercu des manifestations cardiaques et gastro-intestinales du LEAD.

Bag-valve-mask ventilation is generally a safe, and often a life-saving procedure for children who are unable to oxygenate or ventilate by themselves. A case is presented which describes a malfunctioning expiratory valve in a disposable manual bag-valve-mask device resulting in a pneumomediastinum in a child. This is a rare cause of a false-negative colorimetric end-tidal carbon dioxide (ETCO2) reading after endotracheal intubation. However, it is important to recognize so that further adverse outcomes can be prevented.

Traumatic torticollis is an uncommon complaint in the emergency department (ED). One important cause in children is atlantoaxial rotary subluxation. Most children present with pain, torticollis ("cock-robin" position), and diminished range of motion. The onset is spontaneous and usually occurs following minor trauma. A thorough history and physical examination will eliminate the various causes of torticollis. Radiographic evaluation will demonstrate persistent asymmetry of the odontoid in its relationship to the atlas. Computed tomography, especially a dynamic study, may be needed to verify the subluxation. Treatment varies with severity and duration of the abnormality. For minor and acute cases, a soft cervical collar, rest, and analgesics may be sufficient. For more severe cases, the child may be placed on head halter traction, and for long-standing cases, halo traction or even surgical interventions may be indicated. We describe two patients with atlantoaxial rotary subluxation, who presented with torticollis, to illustrate recognition and management in the ED.

Our purpose was to determine if core hypothermia influences physiological responses to norepinephrine (NE); and if rewarming reverses these effects. Animals were instrumented to measure mean arterial pressure (MAP) and cardiac output (CO). Core temperature was manipulated from 37.5 degrees C (normothermia), to 30 degrees C (hypothermia) and the back to 37.5 degrees C (rewarming) using an external arterial-venous femoral shunt. At each of these temperatures, baseline CO and MAP were measured. Norepinephrine (NE) was infused at rates to deliver 0.2, 1.0, or 5 microg kg(-1) per h. At each dose CO and MAP was measured again. Systemic vascular resistance (SVR) was calculated using the formula (SVR = (MAP/CO) x 80). Eight animals underwent all three phases of the protocol. The response to NE during normothermia was a significant increase in MAP to doses of 1 microg kg(-1) per min (P0.01) and 5 microg kg(-1) per min (P0.01) and SVR to doses of 1 microg kg(-1) per min (P0.01) and 5 microg kg(-1) per min (P0.01). The response to NE during hypothermia was a significant increase in MAP only at doses of 1 microg kg(-1) per min (P = 0.03) and 5 microg kg(-1) per min (P = 0.01). The response to NE after rewarming was a significant increase in MAP only at a dose of 5 microg kg(-1) per min (P = 0.03). This study shows that core hypothermia causes a change in physiological response to NE that rewarming does not reverse.

BACKGROUND Heatstroke can result in significant diffuse tissue derangement, which can result in multiple organ system dysfunction. The heart can equally be affected and ischemia and infarction may occur. OBJECTIVE This study aimed to present the potential complications from heatstroke to the myocardium. CASE A case of a 15-year-old adolescent boy who collapsed after playing football in a hot summer day was found to be hyperthermic and poorly perfused. He had ischemic electrocardiographic changes and elevated cardiac enzymes but with normal coronary arteries. CONCLUSIONS Heatstroke can lead to morbidity and mortality. Tissue damage during heatstroke is believed to result from uncoupling during oxidative phosphorylation. It is important to realize that heart damage can occur from heatstroke and that appropriate diagnostic and therapeutic measures are required for a good outcome.

Background: Hyperleukocytosis in acute leukemia is associated with lymphadenopathy, hepatosplenomegaly, disseminated intravascular coagulation, and central nervous system complications. Patients with hyperleukocytosis have lower complete remission rates and have a higher mortality rate, primarily from intracranial hemorrhage. Objectives: To present the potential complications from extreme leukocytosis. Case Report: A 76-year-old man presented to the Emergency Department with chest pain, right-sided weakness, and decreased responsiveness. He was diagnosed with both an acute stroke and myocardial infarction due to extreme leukocytosis from acute myeloid leukemia. Each of these complications by itself would be an unusual manifestation of hyperleukocytosis. To the best of the author's knowledge, this represents the first reported case of these two complications simultaneously from extreme leukocytosis. Conclusions: Patients with acute leukemia may present with hyperleukocytosis, which may result in decreased tissue perfusion. Ischemia occurring in the heart can lead to an acute myocardial infarction, whereas ischemia in the brain can lead to a stroke. These events may, on occasion, be the initial presentation of leukemia. Rapid identification and treatment of the hyperleukocytosis may prevent these complications.

Permanent brain damage caused by ischemia and reperfusion that results from disease processes such as stroke and cardiac arrest (CA) with resuscitation has been estimated to affect approx 200,000 patients in the United States annually (1). Neuronal damage from stroke and CA occur by different mechanistic models of injury. In ischemic stroke, only a portion of the brain is at risk, and the ischemia is only complete in the center of the vulnerable area. This central area of dense ischemia is surrounded by a penumbral zone in which blood flow is diminished but not completely lost. As opposed to CA with resuscitation, flow ceases altogether and the entire brain is at risk for a transient period of complete ischemia followed by reperfusion (2).

Seriously ill patients often face tragically difficult choices. Commonly, an advanced resuscitative intervention offers a chance of longer life, with a chance, too, of profound suffering. In a given day, all over the world, thousands undergo the procedure of cardiopulmonary resuscitation (CPR), whereas others are placed on a “do not attempt resuscitation” (DNAR) status. In the United States, it has been estimated that approx 100,000 lives may be saved with advanced resuscitation (1). The performance of CPR, however, may conflict with the patient’s own desires and may not be in his or her best interest, especially if suffering from a terminally ill condition. It has also been shown that up to 20% of individuals do not wish to be resuscitated (2,3). Decisions concerning CPR are complicated by the fact that often the decision to initiate CPR must be made within seconds by health care providers who generally have very little knowledge about the patient’s illness or of any existing advance directives.

Young infants may present to an emergency department after an acute life-threatening event. The differential diagnosis for an acute life-threatening event is quite extensive. Fortunately, most will have benign or treatable causes. A case of Sturge-Weber syndrome is described in a 2-day old who presented to the emergency department after an acute life-threatening event. A thorough history and detailed physical examination are generally helpful in discerning the etiology for most acute life-threatening events and may at times reveal unusual diseases such as Sturge-Weber syndrome.

Myocardial ischemia in children is generally not suspected when they present to an emergency department with congestive heart failure. However, the opposite holds true for an adult patient. Elevated cardiac troponin is a specific biochemical marker for myocardial damage for both adults and children, however, they have not been routinely used in children at risk for myocardial damage. A case is presented of an infant with a complex congenital heart defect with congestive heart failure who was found to have an elevated cardiac troponin. Infants at risk for myocardial damage should have an evaluation of cardiac markers, as infants with elevated levels are prone to dysrhythmias or worsening cardiac function and thus warrant closer observations and therapy.

Cystic fibrosis is a genetic disorder characterized by chronic obstructive pulmonary disease, pancreatic exocrine deficiency, and abnormally high sweat electrolyte concentrations. Less frequently, the presenting features in infants may include edema, anemia, hypoproteinemia, and acrodermatitis enteropathica. Liver involvement may produce hepatomegaly and mild elevation of transaminases. This clinical symptom usually presents within the first 6 months of life and is associated with a high morbidity and mortality. Early recognition and institution of appropriate nutritional supplementation and pancreatic enzymes is essential to improve outcome. Since the sweat test may be falsely negative, emergency physicians must maintain a high index of suspicion to make the diagnosis of cystic fibrosis in an infant who presents with edema, anemia, hypoproteinemia, and acrodermatitis enteropathica.

Thrombotic thrombocytopenic purpura (TTP) is a rare clinical entity. It is a multi-systemic disorder characterized by a clinical pentad of thrombocytopenia, microangiopathic hemolytic anemia, diffuse and nonfocal neurologic symptoms, decreased renal function, and fever. Abdominal pain is an uncommon presenting symptom for TTP. Pancreatitis may occur from TTP or, in a few cases, may trigger TTP. The clinical diagnosis of TTP is generally difficult because there are many varied clinical presentations and the full expression of the pentad may be prolonged. However, once the diagnosis is suspected or confirmed, immediate plasmapherseis with plasma exchange must be performed to reduce the severe morbidity from neurologic disability.

Crack, the free-base form of cocaine, causes pulmonary, cardiac, obstetric, neurologic, musculoskeletal, and gastrointestinal complications. As the popularity for crack use increases, it follows that the number of cocaine-related emergency department (ED) visits, hospitalizations, and deaths should increase. We report 3 cases of patients arriving to the ED with acute onset of abdominal pain after smoking crack. These patients required surgical correction of their intestinal perforations. Although the exact pathophysiology of intestinal ischemia is not known, cocaine blocks the reuptake of norepinephrine, which leads to mesenteric vasoconstriction and focal tissue ischemia that may lead to perforation. The chronologic relationship of crack consumption to gastrointestinal perforation leads us to surmise that a possible crack-related ischemic event is the cause of perforation in these patients. Physicians examining patients with abdominal pain should be aware of the potential gastrointestinal complications of crack and consider bowel ischemia whenever a cocaine abuser presents with abdominal pain.

Blastomycosis is an unusual fungal infection in children. It is often a chronic infection characterized by granulomatous and suppurative lesions. Clinical manifestations include either pulmonary findings or disseminated disease. Disseminated blastomycosis usually begins with a lung infection that spreads to the skin, bones, and central nervous system. This is a case report of a child with chronic blastomycosis presenting with chronic paronychia, fever, cough, malaise, and back pain. The child underwent surgical drainage of a paravertebral abscess and administration of intravenous amphotericin B. He was discharged in good condition on oral therapy with ketoconazole. The literature on blastomycosis, with particular emphasis on clinical presentations and management, is reviewed. When the history and physical examination suggest a chronic granulomatous or disseminated disease, such as tuberculosis, the physician must include blastomycosis in the differential.

Isolated dislocation of the scapula is a rare entity encountered in the emergency department. Two mechanisms have been proposed, a distraction injury to the arm or direct trauma to the posterior scapula. With blunt trauma, a search for adjacent injuries should be performed. Radiographs, especially anterior oblique views, will demonstrate lateral displacement of the scapula. Acute presentations should be managed by closed reduction, whereas for those presenting later or if the diagnosis is not initially suspected, open surgical reduction may be required. A case is reported of 32-year-old man with a scapular dislocation, and the literature is reviewed.