Maxillofacial injury is commonly seen in the practice of emergency medicine. Major maxillofacial injury itself can be life threatening. Apart from the danger of potential airway compromise, severe haemorrhage from branches of carotid artery causing haemorrhagic shock can occur. Blind techniques, such as packing or ligation of external carotid artery are the usual methods employed to stop the bleeding. However blind techniques carry a significant failure rate. A patient with severe maxillofacial injury and torrential haemorrhage is reported. The bleeding could not be controlled by oral and nasal packing. Emergency selective carotid angiography was performed to identify the source of bleeding and embolization of the bleeding branches successfully arrested the haemorrhage. Interventional radiology could be as effective, if not superior, as an operation in controlling bleeding in selective cases.
Wilms tumor is one of the most treatable childhood cancers even though slightly more than 10% of patients may present with usually silent lung metastases at the time of diagnosis [1,2]. Symptomatic lung disease is exceptional [3,4]. Our experience in managing the superior vena cava (SVC) syndrome secondary to disseminated Wilms tumor in an adolescent patient is therefore of interest.She was a 14-year-old Chinese girl who presented with cough for a month and progressive dyspnea and fever a week prior to admission. There were also night sweats and secondary amenorrhea. Supplementary oxygen was needed to maintain normal oxygen saturation. On physical examination, she was in respiratory distress with tachypnea (60/min). The blood pressure was high (153/105 mm Hg). The face was puffy and the neck was swollen. Super®cial veins were not dilated. The precordial impulses and heart sounds were normal. There was diminished air entry bilaterally without added sounds. A hard mass was palpable over the right hypochrondrium 10 cm below the costal margin. The spleen was not enlarged.On investigation, the patient's blood counts showed hemoglobin of 10.2 g/dl, a white cell count of 10 Â 10 9 / liter without circulating blasts, and a platelet count of 362 Â 10 9 /liter. She was also found to have b-thalassemia trait and hepatitis B surface antigen. The serum biochemistries, including uric acid and liver transaminases, were normal. Human chorionic gonadotrophin and afetoprotein were not elevated. The lactate dehydrogenase was 849 U/liter (normal`683), and the serum renin was 3.08 ng/ml/h (normal 0.2±2.8). The bone marrow aspirate revealed active erythropoiesis with reversed myeloid:erythroid ratio, but was otherwise devoid of malignant in®ltrate.A chest radiograph and CT scan showed a widened mediastinum, bilateral pleural effusions, and multiple large, roundish intraparenchymal and pleural-based masses in both lung ®elds. The ®ndings in the superior mediastinum were surprising. There was a large rightsided paratracheal soft tissue mass encasing the SVC and right brachiocephalic vein with apparently direct extension of the tumor into the lumen of the SVC (Fig. 1). Abdominal imaging showed a heterogeneous mass (9 Â 7.4 cm) arising from the right kidney. The inferior vena cava was compressed but its lumen remained patent without intraluminal thrombus.Small round cell tumor cells were obtained by needle biopsy of one of the pleural masses. They were strongly positive for vimentin, moderately positive for O13, and negative for cam5.2, MNF 116, NSE, synaptophysin, chromogranin, neuro®lament, LCA, desmin, and myoglobin.While the histologic result was awaited, her condition was complicated by spontaneous pneumothorax of the left lung. As the cytologic features were suggestive of a primitive neuroectodermal tumor and the patient's condition was critical, she was promptly put on treatment with vincristine 1.5 mg/m 2 , doxorubicin 75 mg/m 2 , and cyclophosphamide 1,200 mg/m 2 . Her condition improved rapidly after the ®rst course of chemother...
We wish to congratulate the authors on their publication "Acute urinary retention: how useful is an ambulatory care protocol?" [Hong Kong J Emerg Med 2009;16(3):134-140]. We would like to make comments concerning two issues in the study.
Failure of a Foley catheter balloon to deflate is a frustrating problem to both the patient and the doctor. We report a case of non-deflating Foley catheter balloon successfully deflated by needle puncture via the suprapubic route under trans-abdominal ultrasound guidance by emergency physicians. The procedure is simple and safe. We believe that all emergency physicians with adequate knowledge and minimal training can acquire the technique. The choices of different methods to deflate the balloon are also discussed.
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