American Journal of Emergency Medicine

Role of inferior vena cava and right ventricular diameter in assessment of volume status: a comparative study: Ultrasound and hypovolemia

2013-04-19

Abstract: Objective: Ultrasonography has been suggested as a useful noninvasive tool for the detection and follow-up for hypovolemia. Two possible sonographic markers as a surrogate for hypovolemia are the diameters of the inferior vena cava (dIVC) and the right ventricle (dRV). The goal of this study was to evaluate IVC and RV diameters and diameter changes in patients treated for hypovolemia and compare these findings with healthy volunteers.Methods: Fifty healthy volunteers and 50 consecutive hypovolemic patients were enrolled in the study. The dIVC, both during inspiration (IVCi) and expiration (IVCe), was measured in hypovolemic patients both before and after fluid resuscitation, and they were also measured in healthy volunteers during the time they participated in the study. The dIVC, in hypovolemic patients both before and after fluid resuscitation, was measured ultrasonographically by M-mode in the subxiphoid area. The dRV was measured ultrasonographically by B-mode in the third and fourth intercostals spaces.Results: The average diameters of the IVCe, IVCi, and dRV in hypovolemic patients upon arrival were significantly lower compared with healthy volunteers (P = .001). After fluid resuscitation, there was a significant increase in the mean diameters of the IVCe, IVCi, and RV in hypovolemic patients (P = .001).Conclusions: The results indicate that the dIVC and dRV are consistently low in hypovolemic subjects when compared with euvolemic subjects. Bedside serial measurements of dIVC and dRV could be a useful noninvasive tool for the detection and follow-up of patients with hypovolemia and evaluation of the response to the treatment.

Ulinastatin improved cardiac dysfunction after cardiac arrest in New Zealand rabbits

2013-04-19

Abstract: Objective: The present study was designed to evaluate the effects of ulinastatin (UTI) on cardiac dysfunction after cardiopulmonary resuscitation (CPR).Methods: A total of 48 healthy adult male New Zealand rabbits were untreated for 8 minutes after the induction of ventricular fibrillation (VF) by an external transthoracic alternating current and then treated by CPR. These rabbits were then randomly divided into the control and UTI groups after the return of spontaneous circulation (ROSC) and were observed for 8 hours after the ROSC. Before CPR and after ROSC at 2, 4, and 8 hours, blood samples were collected to determine the levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), malondialdehyde (MDA), cardiac troponin I (cTnI), and N-terminal probrain natriuretic peptide (NT-proBNP), and the left ventricular ejection fraction (EF) was measured by echocardiography.Results: Nineteen of 24 rabbits in the control group and 18 of 24 in the UTI group were successfully resuscitated. The plasma levels of TNF-α, IL-6, MDA, cTnI, and NT-proBNP were significantly increased, accompanying a deceased EF in the control group, but the cotreatment with UTI decreased the plasma levels of TNF-α, IL-6, MDA, cTnI, and NT-proBNP (P < .05), attenuating the myocardial injury and improving the EF in the UTI group. Only 9 of 19 animals in the control group but 14 of 18 animals in the UTI group survived longer than 8 hours (P = .011).Conclusions: The progression of proinflammatory responses, oxidative stress, and myocardial injury have been linked to the reduced EF after VF/CPR, and the administration of UTI at a cardioprotective dosage preserved the cardiac function after VF/CPR.

A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding

Cheng-Hsien Wang, Yu-Wei Chen, Yui-Rwei Young, Chia-Jung Yang, I-Chuan Chen — 2013-03-04

Abstract: Background: The clinical severities of upper gastrointestinal bleeding (UGIB) are of a wide variety, ranging from insignificant bleeds to fatal outcomes. Several scoring systems have been designed to identify UGIB high- and low-risk patients. The aim of our study was to compare the Glasgow-Blatchford score (GBS) with the preendoscopic Rockall score (PRS) and the complete Rockall score (CRS) in their utilities in predicting clinical outcomes in patients with UGIB.Methods: We designed a prospective study to compare the performance of the GBS, PRS, and CRS in predicting primary and secondary outcomes in UGIB patients. The primary outcome included the need for blood transfusion, endoscopic therapy, or surgical intervention and was labeled as high risk. The secondary outcomes included rebleeding and 30-day mortality. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values for each system were analyzed. A total of 303 consecutive patients admitted with UGIB during a 1-year period were enrolled.Results: For prediction of high-risk group, AUC was obtained for GBS (0.808), PRS (0.604), and CRS (0.767). For prediction of rebleeding, AUC was obtained for GBS (0.674), PRS (0.602), and CRS (0.621). For prediction of mortality, AUC was obtained for GBS (0.513), PRS (0.703), and CRS (0.620).Conclusions: In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool. However, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.

Differentiation of exudate from transudate ascites based on the dipstick values of protein, glucose, and pH

2013-03-04

Abstract: The aim of present study was to determine the reliability of the dipstick values (protein, glucose, and pH) for differentiation of exudate from transudate ascites in comparison with the serum-ascites albumin gradient as criterion standard. A total of 100 patients with ascites (58 males and 42 females; mean age, 55.6 ± 16.1 years) were studied for the different causes of ascites. Peripheral blood samples were obtained, and at the same time, the patients underwent paracentesis. There were 62 cases (62.0%) of transudate ascites and 38 (38.0%) of exudates ascites, based on serum-ascites albumin gradient. Using logistic regression, we found a dipstick equation (K = 0.012Protein − 0.012Glucose − 3.329pH + 23.498) to differentiate transudate (K < 0) from exudate (K > 0) ascites. The sensitivity, specificity, positive predictive value, and negative predictive value of dipstick equation to diagnose ascites as transudate and exudate were 93.8%, 94.4%, 96.8%, and 89.5%, respectively, and 94.4%, 93.9%, 89.5%, and 96.9%, respectively. The area under the receiver operating characteristic curve was 0.915 (95% confidence interval, 0.848-0.982; P < .001). We concluded that the dipstick can be an inexpensive, rapid, and simple option for categorizing ascites into transudate and exudate and can be used routinely for this purpose in clinical practice.

Atypical presentations of dengue disease in the elderly visiting the ED

Ching-Chi Lee, Hsiang-Chin Hsu, Chia-Ming Chang, Ming-Yuan Hong, Wen-Chien Ko — 2013-02-11

Abstract: Objective: The objective was to compare the clinical characteristics of elderly and young adult patients with dengue in the emergency department (ED).Methods: Demographic characteristics, clinical presentation, disease severity, laboratory characteristics, and outcomes were analyzed prospectively as a case-control study.Results: Of the 193 adults with serologically confirmed dengue disease in 2007, 31 (16.1%) were elderly patients (aged ≥65) and 162 were young adults (aged <65). More dengue hemorrhagic fever (12.9% vs 2.5%, P = .02), a longer ED stay (13.3 vs 8.6 hours, P = .004), a longer hospital stay (7.4 vs 3.4 days, P < .001), a higher Simplified Acute Physiology Score II in the ED (29.7 vs 17.4, P < .001), and a higher rate of at least 1 comorbidity (61.8 vs 22.8%, P < .001) were found in the elderly. However, the length of the intensive care unit stay (elderly 0.7 vs young adults 0.3 day, P = .47) and the 14-day mortality rate (0% vs 0.6%, P = 1.00) were similar. Of note, in terms of clinical presentations of dengue in the ED, there were more elderly patients with isolated fever (41.9% vs 17.9%, P = .003) and fewer with typical presentation (41.9% vs 75.9%, P = <.001) than there were young adults.Conclusions: The present study found a higher number of atypical presentations, a longer hospitalization, and a higher degree of clinical illness in elderly patients with dengue.

Factors associated with use of emergency medical services in patients with acute stroke

2013-03-04

Abstract: Purposes: The aim of this study was to investigate the factors associated with use of emergency medical services (EMS) in patients with acute stroke.Methods: Prospective data on consecutive patients with acute stroke who presented to the emergency department of a university medical center from January 1, 2010, to July 31, 2011, were analyzed. Patients were excluded if they had an unknown residence, had onset of stroke at a nursing home or hospital, or were transferred from another hospital. Variables for all patients with stroke and ischemic stroke who did and did not use EMS were compared.Results: In total, 1344 patients (60% male; mean age, 68.7 years) were included. Use of EMS (n = 409; 30.4%) was significantly associated with a higher level of education (≧6 years vs <6 years; odds ratio [OR], 1.69; 95% confidence interval [CI], 1.25-2.29), a higher National Institutes of Health Stroke Scale score (OR, 1.08; 95% CI, 1.05-1.11), altered consciousness (OR, 1.88; 95% CI, 1.25-2.84), and atrial fibrillation (OR, 2.43; 95% CI, 1.71-3.44) after adjustment. For patients with ischemic stroke, use of EMS was significantly higher in cases of cardioembolism (OR, 3.04; 95% CI, 1.40-6.60) and large artery atherothrombosis (OR, 2.10; 95% CI, 1.22-3.62) than lacunar infarction.Conclusion: Patients with stroke who have altered consciousness, a higher level of education, a higher National Institutes of Health Stroke Scale score, atrial fibrillation, and cardioembolic stroke were more likely to use EMS.

Evaluating the HATCH score for predicting progression to sustained atrial fibrillation in ED patients with new atrial fibrillation

2013-03-13

Abstract: Objectives: Atrial fibrillation (AF) is often first detected in the emergency department (ED). Not all AF patients progress to sustained AF (ie, episodes lasting >7 days), which is associated with increased morbidity. The HATCH score stratifies patients with paroxysmal AF according to their risk for progression to sustained AF within 1 year. The HATCH score has previously never been tested in ED patients. We evaluated the accuracy of the HATCH score to predict progression to sustained AF within 1 year of initial AF diagnosis in the ED.Methods: We conducted a retrospective cohort study of 253 ED patients with new onset AF and known rhythm status for 1 year following the initial AF detection. The exposure variable was the HATCH score at initial ED evaluation. The primary outcome was rhythm status at 1 year following initial AF diagnosis. We constructed a receiver operating characteristic curve and calculated the area under the curve to estimate the HATCH score's accuracy of predicting progression to sustained AF.Results: Overall, 61 (24%) of 253 of patients progressed to sustained AF within 1 year of initial detection, and the HATCH score receiver operating characteristic area under the curve was 0.62 (95% confidence interval, 0.54-0.70).Conclusions: Among ED patients with new onset AF, the HATCH score was a modest predictor of progression to sustained AF. Because only 2 patients had a HATCH greater than 5, this previously recommended cut-point was not useful in identifying high-risk patients in this cohort. Refinement of this decision aid is needed to improve its prognostic accuracy in the ED population.

An after-action review tool for EDs: learning from mass casualty incidents

2013-03-07

Abstract: Background: Conducting a thorough after-action review (AAR) process is an important component in improving preparedness for mass casualty incidents (MCIs).Purposes: The study aimed to develop a structured AAR tool for use by medical teams in emergency departments after an MCI and to identify the best possible procedure for its conduct.Basic procedures: On the basis of knowledge acquired from an extensive literature review, a structured tool for conducting an AAR in the emergency department was developed. A modified Delphi process was conducted to achieve content validity of the tool, involving 48 medical professionals from all 6 level I trauma centers in Israel. The AAR tool was tested during a simulated MCI drill.Main findings: All experts support the conduct of an AAR in the ED after an MCI to build and maintain capacity for an adequate emergency response. More than 80% agreement was achieved regarding 14 components that were implemented in the proposed AAR tool. Ninety-four percent perceived that AARs should be conducted within 24 hours from the event using both written reports and face-to-face discussions. Both physicians and nurses should participate. The incident manager should lead the AAR, limiting the time allocated for each speaker and for the AAR in whole.Principle conclusions: Conducting a structured AAR in all emergency departments after an MCI facilitates both learning lessons regarding the function of the medical staff and ventilation of feelings, thus mitigating anxieties and expediting a speedy return to normalcy.

Swimming injuries treated in US EDs: 1990 to 2008

Katherine A. Pollard, Bethany L. Gottesman, Lynne M. Rochette, Gary A. Smith — 2013-03-13

Abstract: Objective: Swimming is one of the most popular recreational activities in the United States. The objective of this study was to investigate the epidemiology of the complete spectrum of injuries associated with swimming and swimming pools treated in US hospital emergency departments.Methods: Data from the National Electronic Injury Surveillance System from 1990 to 2008 were analyzed. Injury rates were calculated using US census swimming participation data.Results: An estimated 1688924 swimming injuries occurred during the 19-year study, averaging 1 injury every 6 minutes. During the study period, the number of injuries and rate of injury among individuals 7 years or older significantly increased. Within this trend, injuries peaked in 1999 and significantly decreased during the last 10 years but still showed an overall increase of 18.6% in number and 29.3% in rate from 1900 to 2008. Patients 17 years or younger accounted for 60.5% of injuries, and patients 7 to 17 years of age had a greater mean annual swimming injury rate (18.78 per 10000 participants) than patients older than 17 years (9.15). Most injuries occurred in or around a swimming pool (87.0%), and most were soft tissue injuries (54.7%), followed by strains/sprains (16.4%), fractures/dislocations (11.3%), and submersion (4.9%). Injuries to patients younger than 7 years, submersion injuries, and injuries occurring at home were more likely to result in hospital admission or fatality.Conclusions: The observed increase in injuries among individuals older than 7 years underscores the need for increased prevention efforts, including education about safe swimming practices, supervision, and environmental modifications.

Ultrasound guidance for radial arterial puncture: a randomized controlled trial

2013-03-26

Abstract: Study Objective and Background: Arterial puncture for blood gas analysis is a frequent procedure and could be difficult in the emergency setting. The aim of the study was to compare ultrasonographically guided arterial radial puncture vs conventional sampling.Materials and Methods: This is a prospective, randomized study. The inclusion criteria are all patients needing arterial blood gas at admission in the emergency unit. The exclusion criteria are the following: Hallen test positive, local sepsis, local trauma, known sever local arteriopathy, refusal of consent by the patient, participation in another study, and cardiac arrest. Patients were randomized into 2 groups: radial arterial puncture obtained through an ultrasonographically guided technique (group 1) or radial arterial puncture by conventional method (group 2). The main objective is the number of attempts after enrollment. The secondary objectives are time to success, patient satisfaction and pain, and physician satisfaction. Immediate complications were collected. Groups were compared with nonparametric analysis.Results: The data were usable for 72 of 74 patients included. Lung disease (acute exacerbation of chronic obstructive pulmonary disease and pneumonia) at 45% (n = 32) and suspicion of pulmonary embolism in 31% (n = 22) were the most common reasons. Demographics data were comparable in the 2 groups. In group 1, the number of attempts significantly increased (2.35 [1-3] vs 1.66 [1-2] [P = .017]), and the sample was 2.4 times longer (132 seconds [50-200] vs 55 [20-65] [P < .01] by standard method). There was no significant difference in terms of pain (visual analog scale [VAS], 3.6 [2-5] for both groups [P = .743]), patient satisfaction (VAS, 7.2 [5-9] vs 6.8 [5-9] [P = .494]), and physician satisfaction (VAS, 6.0 [3.5-8] vs 6.9 [5-9] [P = .233]). No immediate complications were found in the 2 groups.Conclusion: Ultrasonographically guided arterial puncture increases the number and duration of implementations. This technique, however, does not alter the patient's pain, the number of immediate complications, or patient and physician satisfaction.

Cytokine markers as predictors of type of respiratory infection in patients during the influenza season

John Patrick Haran, Rachel Buglione-Corbett, Shan Lu — 2013-03-07

Abstract: Objective: The objective of this study is to characterize the cytokine response among patients presenting with an influenza-like illness who are infected with the influenza virus, a bacterial pneumonia, or another viral infection. We hypothesize that there are differences in proinflammatory and anti-inflammatory cytokines in relation to cytokines associated with the humoral response during viral and bacterial respiratory infections.Methods: We enrolled adults who presented to an urban academic emergency department during the 2008 to 2011 influenza seasons with symptoms of fever and a cough. Subjects had nasal aspirates tested by viral culture, and peripheral blood drawn to quantify cytokine concentrations. Cytokine concentrations were compared between groups using the Wilcoxon rank sum test, and receiver operating characteristic curves were calculated.Results: A total of 80 patients were enrolled: 40 with influenza infection, 14 patients with a bacterial pneumonia as determined by infiltrate on chest x-ray, and 26 patients negative for influenza infection and infiltrate. There were differences between the bacterial pneumonia group, and all other viral infections grouped together with regard to interleukin (IL) 4 (2.66 vs 16.77 pg/mL, P < .001), IL-5 (20.57 vs 57.57 pg/mL, P = .006), IL-6 (403.06 vs 52.69 pg/mL, P < .001), granulocyte macrophage colony-stimulating factor (18.26 vs 66.80 pg/mL, P < .001), and interferon γ (0.0 vs 830.36 pg/mL, P < .001). Interleukin 10 concentrations were elevated in patients with influenza (88.69 pg/mL) compared with all other groups combined (39.19 pg/mL; P = .003).Conclusion: Cytokines IL-4, IL-5, IL-6, granulocyte macrophage colony-stimulating factor, and interferon γ may serve as distinct markers of bacterial infection in patients with an influenza-like illness, whereas IL-10 is uniquely elevated in influenza patients.

Impact of ED management on hospital quality measures: the negative case of atrial fibrillation

Nicole E. Piela, Alfred Sacchetti, Darius Sholevar, Reginald Blaber, Steven Levi — 2013-03-07

Abstract: Objective: Emergency department (ED) cardioversion and discharge of atrial fibrillation (AF) is an evolving treatment. Emergency department cardioversion patients have few comorbidities, and their discharge directly from the ED leads to a sicker in-patient population of AF patients. This study examines whether the quality care markers, hospital charges (HC) and length of stay (LOS), negatively reflect the practice of ED cardioversion.Methods: Median HC and LOS were determined for 2 different quality assessment reporting models. In a standard model (SM), patients discharged from the ED were not included in any hospital statistics and only admitted, or observation patients were used to calculate the HC and LOS of AF patients. In an inclusive model (IM), patients discharged from the ED were also included in the hospital statistics but given the same LOS as observation patients. Differences across medians were analyzed using Wilcoxon rank sum tests.Results: A total of 312 patients were evaluated for AF over an 18-month period. Of these, 197 (62%) were admitted, 21 (7%) were placed in observation status, and 95 (31%) were discharged from the ED. Median values for LOS were 3 days (interquartile range [IQR], 1-5) for the SM and 1 day (IQR, 0-4) for the IM. Median values for HC were $33062 (IQR, $19267-$60614) for the SM and $20059 (IQR, $4249-$47195) for the IM.Conclusion: Emergency department cardioversion selects out a less sick cohort of patients whose removal from a hospital's admission numbers negatively skews quality performance profiles.

Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED

Sheng-Liang Chung, Meng-Huan Lei, Chao-Chin Chen, Yu-Cheng Hsu, Chih-Chieh Yang — 2013-03-13

Abstract: Background: There are several causes of ST-segment elevation (STE) besides acute myocardial infarction (MI).Objectives: We design this study to determine the prevalence, etiology, clinical manifestation, electrocardiographic characteristics, and outcome in patients with false-positive STEMI.Methods: This is a retrospective case-control study design. At our emergency department, 297 patients who underwent emergent coronary angiography for suspected STEMI were enrolled from January 2004 to December 2010.Results: Of the 297 patients who underwent coronary angiography, 31 patients (10.4%) did not have a clear culprit coronary lesion and were classified as false-positive STEMI. False-positive STEMI patients had a lower incidence of typical chest pain or chest tightness (58.1% vs 87.6%, P < .001). Inferior STE occurred significantly more often in the patients with true-positive STEMI (49.6% vs 25.8%, P = .012), and diffuse STE, more often in the patients with false-positive STEMI (19.4% vs 0.38%, P = .001). Total height of STE was lower in false-positive STEMI patients (7.5 ± 4.9 vs 10.9 ± 7.9 mm, P = .002) if excluding 5 patients of marked STE just after cardiopulmonary resuscitation. Concave STE and no reciprocal ST-segment depression occurred more often in false-positive STEMI patients (51.6% vs 24.1%, P = .001; 64.5% vs 19.2%, P < .001). There was no significant difference of in-hospital major adverse events in the patients with false-positive and true-positive STEMI.Conclusions: The diagnosis of false-positive STEMI is not uncommon. Detailed clinical evaluation and electrocardiogram interpretation may avoid partly unnecessary catheterization laboratory activation.

Predicting the hyperglycemic crisis death (PHD) score: a new decision rule for emergency and critical care

2013-04-22

Abstract: Background: We investigated independent mortality predictors of hyperglycemic crises and developed a prediction rule for emergency and critical care physicians to classify patients into mortality risk and disposition groups.Methods: This study was done in a university-affiliated medical center. Consecutive adult patients (> 18 years old) visiting the emergency department (ED) between January 2004 and December 2010 were enrolled when they met the criteria of a hyperglycemic crisis. Data were separated into derivation and validation sets—the former were used to predict the latter. December 31, 2008, was the cutoff date. Thirty-day mortality was the primary endpoint.Results: We enrolled 295 patients who made 330 visits to the ED: derivation set = 235 visits (25 deaths: 10.6%), validation set = 95 visits (10 deaths: 10.5%). We found 6 independent mortality predictors: Absent tachycardia, Hypotension, Anemia, Severe coma, Cancer history, and Infection (AHA.SCI). After assigning weights to each predictor, we developed a Predicting Hyperglycemic crisis Death (PHD) score that stratifies patients into mortality-risk and disposition groups: low (0%) (95% CI, 0-0.02%): treatment in a general ward or the ED; intermediate (24.5%) (95% CI, 14.8-39.9%): the intensive care unit or a general ward; and high (59.5%) (95% CI, 42.2-74.8%): the intensive care unit. The area under the curve for the rule was 0.946 in the derivation set and 0.925 in the validation set.Conclusions: The PHD score is a simple and rapid rule for predicting 30-day mortality and classifying mortality risk and disposition in adult patients with hyperglycemic crises.

Don't get sick on the weekend: an evaluation of the weekend effect on mortality for patients visiting US EDs

Adam L. Sharp, HwaJung Choi, Rod A. Hayward — 2013-03-04

Abstract: Primary objective: The primary objective of the study is to determine if the mortality for adult patients visiting US emergency departments (EDs) is greater on weekends than weekdays.Secondary objectives: The secondary objective of the study is to examine whether patient factors (diagnosis, income, insurance status) or hospital characteristics (ownership, ED volume, teaching status) are associated with increased weekend mortality.Methods: We used a retrospective cohort analysis of the 2008 Nationwide Emergency Department Sample. Evaluating 4225973 adults admitted through the ED to the hospital, signifying a 20% representative sample of US ED admissions. Logistic regression was used to examine associations of weekend mortality with patient and hospital characteristics, accounting for clustering by hospital.Results: Emergency department patients admitted to the hospital on the weekend are significantly more likely to die than those admitted on weekdays (odds ratio, 1.073; 95% confidence interval, 1.061-1.084). A significant weekend effect persisted after controlling for patient characteristics (odds ratio, 1.026; 95% confidence interval, 1.005-1.048). The top 10 primary diagnoses for patients dying did not identify any specific medical condition that explained the higher weekend admission mortality. The weekend effect was also relatively consistent across patient income, insurance status, hospital ownership, ED volume, and hospital teaching status.Conclusion: Patients are more likely to die when admitted through the ED on the weekend. We were unable to identify specific circumstances or hospital attributes that help explain this phenomenon. Although the relative increased risk per case is small, our study demonstrates a significant number of potentially preventable weekend deaths occurring annually in the United States.

Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older

2013-03-13

Abstract: Purpose: Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups.Basic procedures: Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older.Main findings: The primary analysis included 33906 subjects (101837 weighted) 10 years and older. The secondary analysis included 13393 subjects (37983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years.Conclusions: This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.

Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types

2013-02-28

Abstract: Objective: To identify and evaluate the volume, nature, and severity of patient presentations encountered by emergency medical services (EMS) at all mass-gathering events held at or near a southeastern US university. In addition, to compare the existing literature base (single mass-gathering event held in large urban population centers) with a broader variety of events varying in crowd size and locations.Methods: This was a retrospective review of all EMS records from mass-gathering patient presentations (individual-patient cases) between October 24, 2009, and August 27, 2011. All patrons seen by event-based EMS were included. Events categories included the following: football, concerts, public exhibitions, and nonfootball athletic events. Event volumes were defined as follows: low (<1000 patrons), medium (between 1001 and 15 000 patrons), and large (>15 000 patrons). Case presentation-management categories included the following: trauma, medical, and support (minimal medical intervention required, eg, minor dressing for abrasion, water, etc). Severity categories included the following: mild, moderate, and severe based on the following definitions using both provider assessment and the use of transport to a hospital: minor cases were considered non–life threats and did not result in a transport to a hospital; moderate cases were associated with transports to a hospital; and severe cases were life threats with transport to a hospital.Results: We studied 79 events over the study period. Event volumes were 16.45% high, 79.75% medium, and 3.80% low. A total of 670 cases presented, with a mean of 8.48 cases/event. The football category had the highest mean number of cases with 37.09 cases/event, for a total of 408 cases. The nonfootball, athletic event category had the lowest mean number of cases at 1.83 cases/event. Most (81.82%) of the football events were classified as large volume. Support cases were the most common presentation (43.13%), followed closely by medical complaints (41.94%). Most cases were mild in severity (95.97%). There were 27 cases requiring transport to hospital, with 3 cases being life-threatening. The average patient age was 33 years, with 60.3% female sex. These features are similar to the published information on large event medical attendance.Conclusions: In this retrospective, descriptive study of a broad range of event type, the most common patient presentations at mass-gathering events were mild in severity, requiring minimal medical intervention. Both transports from the event to a hospital and the occurrence of life threats were uncommon. Our findings are similar to the data found in the existing medical literature.

Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain

Terence L. Ahern, Andrew A. Herring, Michael B. Stone, Bradley W. Frazee — 2013-04-22

Abstract: Objective: We assessed the analgesic effect and feasibility of low-dose ketamine combined with a reduced dose of hydromorphone for emergency department (ED) patients with severe pain.Methods: This was a prospective observational study of adult patients with severe pain at an urban public hospital. We administered 0.5 mg of intravenous (IV) hydromorphone and 15 mg of IV ketamine, followed by optional 1 mg hydromorphone IV at 15 and 30 minutes. Pain intensity was assessed at 12 intervals over 120 minutes using a 10-point verbal numerical rating scale (NRS). Patients were monitored throughout for adverse events. Dissociative side effects were assessed using the side effects rating scale for dissociative anesthetics.Results: Of 30 prospectively enrolled patients with severe pain (initial mean NRS, 9), 14 reported complete pain relief (NRS, 0) at 5 minutes; the mean reduction in NRS pain score was 6.0 (SD, 3.2). At 15 minutes, the mean reduction in NRS pain score was 5.0 (SD, 2.8). The summed pain intensity difference and percent summed pain intensity difference scores were 25 (95% confidence interval [CI], 21-30) and 58% (95% CI, 49-68) at 30 minutes and 41 (95% CI, 34-48) and 50% (95% CI, 42-58) at 60 minutes, respectively. Most patients (80%) reported only weak or modest side effects. Ninety percent of patients reported that they would have the medications again. No significant adverse events occurred.Conclusions: Low-dose ketamine combined with a reduced dose hydromorphone protocol produced rapid, profound pain relief without significant side effects in a diverse cohort of ED patients with acute pain.

A descriptive study of myoclonus associated with etomidate procedural sedation in the ED

Adam M. Yates, Allan B. Wolfson, Leo Shum, Thompson Kehrl — 2013-04-03

Abstract: Background: Myoclonus is a well-recognized side effect of etomidate when given in induction doses for rapid sequence intubation. Most of the data reported on myoclonus with emergency department (ED) sedation doses are reported as a secondary finding.Study objectives: Our objective was to prospectively quantify the incidence and duration of myoclonus associated with the administration of etomidate in the lower doses given for procedural sedation in the ED.Methods: This was a prospective descriptive study performed between September 2008 and September 2010 at an urban teaching hospital ED with approximately 50000 patient visits per year. Procedural sedation was performed at the discretion of the treating emergency physician, and adult patients receiving etomidate were eligible for enrollment. The occurrence and duration of myoclonus were observed and recorded. Any interference of myoclonus with the ability to complete the procedure was recorded, and adverse effects were identified.Results: Thirty-four eligible subjects were enrolled, and 36 separate sedation procedures were performed. The mean initial etomidate dose was 0.13 mg/kg (range, 0.077-0.20), and the mean total etomidate dose was 0.15 mg/kg (range, 0.077-0.29). Myoclonus was noted in 26 (72%) of 36 sedations. Mean time to onset of myoclonus was 50 seconds (range, 15-146), and the mean duration was 93 seconds (range, 03-557). Myoclonus interfered with the procedure in only 1 (3%) of 36 attempted procedures, and no procedure was unsuccessful because of myoclonus.Conclusion: Myoclonus associated with sedation doses of etomidate was common but rarely interfered with the completion of a procedure.

Risk factors for ED use among homeless veterans

Jack Tsai, Robert A. Rosenheck — 2013-04-08

Abstract: Despite national concern about homeless veterans, there has been little examination of their use of emergency department (ED) services. This study examines factors related to the use of ED services in the Veterans Affairs (VA) healthcare system, where insurance is not a barrier to ambulatory healthcare. National VA administrative data from fiscal year 2010 are used to describe the proportions of ED users among homeless and domiciled VA patients. A case-control design is then used to compare homeless ED and non-ED users on sociodemographic and clinical correlates, as well as use of ambulatory care and psychotropic medications. Sixteen percent of domiciled VA patients used EDs at least once during the year and 1% were frequent ED users (>4 ED visits) compared to 45% of homeless VA patients, 10% who were frequent ED users. Among homeless VA patients, those who used EDs were more likely to have a range of psychiatric and medical conditions, and had more service visits and psychotropic medication prescriptions than non-ED users. Multivariate analyses suggest their risk for psychiatric and medical conditions increase their likelihood of using ED services. The high rate of ED use among homeless veterans is associated with significant morbidity, but also greater use of ambulatory care and psychotropics suggesting their ED use may reflect unmet psychosocial needs.

ED management of patients with eating disorders

Stacy A. Trent, Maria E. Moreira, Christopher B. Colwell, Philip S. Mehler — 2013-04-26

Abstract: Background: Eating disorders are one of the “great masqueraders” of the twenty-first century. Seemingly healthy young men and women with underlying eating disorders present to emergency departments with a myriad of complaints that are not unique to patients with eating disorders. The challenge for the Emergency Medicine physician is in recognizing that these complaints result from an eating disorder and then understanding the unique pathophysiologic changes inherent to these disorders that should shape management in the emergency department.Objective: In this article, we will review, from the perspective of the Emergency Medicine physician, how to recognize patients with anorexia and bulimia nervosa, the medical complications and psychiatric comorbidities, and their appropriate management.Conclusions: Anorexia and bulimia nervosa are complex psychiatric disorders with significant medical complications. Recognizing patients with eating disorders in the ED is difficult, but failure to recognize these disorders, or failure to manage their symptoms with an understanding of their unique underlying pathophysiology and psychopathology, can be detrimental to the patient. Screening tools, such as the SCOFF questionnaire, are available for use by the EM physician. Once identified, the medical complications described in this article can help the EM physician tailor management of the patient to their underlying pathophysiology and effectuate a successful therapeutic intervention.

Electrocardiographic implications of the prolonged QT interval

2013-04-22

Abstract: The QT interval measures the time from the start of the QRS complex to the end of the T wave. Prolongation of the QT interval may lead to malignant ventricular tachydysrhythmias, including torsades de pointes. Causes of QT prolongation include congenital abnormalities of the sodium or potassium channel, electrolyte abnormalities, and medications; idiopathic causes have also been identified. Patients can be asymptomatic or present with syncope, palpitations, seizure-like activity, or sudden cardiac death. Management involves looking for and treating reversible causes. For patients with congenital or idiopathic QT interval prolongation, the use of beta-blockers can be considered. Certain subsets of patients benefit from implantation of a cardioverter-defibrillator. Clinicians must remain vigilant for QT interval prolongation when interpreting electrocardiograms, especially in patients presenting with syncope or ventricular arrhythmias.

“Relaxed” reference formatting: a digital dividend for authors

J. Douglas White — 2013-05-01

In the digital publication era, online links are critical to the discoverability of research, citation, indexing, abstraction and high quality peer review. Yet when researchers are asked what professional task they find most frustrating, nearly one in three choose “preparing manuscripts” . In particular, formatting references contributes greatly to this burden, taking an average of over 3 hours of authors’ time, even when reference management software is used .

Comment on “A new electrocardiogram finding for massive pulmonary embolism: ST elevation in lead aVR with ST depression in leads I and V4 to V6”

Piotr Kukla, Leszek Bryniarski, Marek Jastrzębski, Ewa Krupa — 2013-03-13

We have read with a great interest the article by Zhong-qun et al concerning electrocardiographic (ECG) changes in massive acute pulmonary embolism (APE) . The authors presented 3 patients with APE and deterioration of clinical status during the hospitalization. They pay attention to a combination of the following electrocardiographic features: ST-segment elevation in lead aVR and ST-segment depression in leads I, V4 to V6 . This ECG pattern may be helpful in patients with suspected or recognized APE in the rapid identification of high-risk patients who may benefit from thrombolytic therapy or mechanical intervention. In a study that we performed, the number of leads with negative T waves, the presence of right bundle-branch block, and ST-segment elevation in leads V1 (odds ratio, 3.99; P = .00017) and aVR (odds ratio, 2.49; P = .011) were independent predictors of complications during hospitalization . All 3 cases presented by Zhong-qun et al display QR (qR) sign (known as Kuscher sign) with the different combination of subtle ST-segment elevation in leads III and/or aVR and/or V1 and/or V3R. The aforementioned ECG features and ST-segment depression in lateral leads observed by Zhong-qun et al are significantly more common in patients with elevated troponin vs patients with normal troponin level. Our study showed that ST-segment depression in V4 to V6 (40% vs 14%; P = .001), ST-segment elevation in III (22% vs 7%; P = .0006), V1 and V2 (43% vs 10%; P = .0001), and QR in V1 (16% vs 5%; P = .007) were more common in patients with elevated troponin vs patients with normal troponin level . More recently, we assessed the frequency of ST-segment elevation (STE) in lead aVR in patients with APE . We found STE in lead aVR in 45.3% patients. In comparison with patients without STE, patients with STE in lead aVR had significantly more often systolic blood pressure less than 90 mm Hg on admission (27% vs 10%; P < .001) and positive troponin level (64.8% vs 27.9%; P < .001). Thrombolytic therapy (14.3% vs 5.6%; P = .009) and catecholamines (29.3% vs 7.5%; P < .001) were more frequently used in patients with STE in lead aVR. The overall mortality (16.5% vs 6.9%; P = .009) and complication rates during hospitalization (38.3% vs 12.5%; P < .001) were significantly higher in patients with STE in lead aVR . The STE in lead aVR was significantly more frequent in patients with negative T waves in inferior leads, STE in lead III, STE in lead V1, ST depression in lead V4 to V6, right bundle-branch block, QR sign in lead V1, and SI-QIII-TIII sign .

Performance improvement in emergency tourniquet use during the Baghdad surge

2013-03-07

Recently, we studied emergency tourniquet use, a vital need in war casualties, to stop bleeding, and knowledge generated helped to improve survival at a low risk of morbidity . We sought to document the impact of process improvement efforts over time on tourniquet success rates, the use of other hemorrhage control measures in conjunction with tourniquets, and the rate at which prehospital tourniquets were converted to pressure dressings as doctrine suggests . The 3 sequential periods surveyed corresponded to the precondition, the preparation, and the execution of the Baghdad surge; in comparison with the 2 previously reported periods, we report the third period now. The purposes of the present study are to (1) survey tourniquet use to fill knowledge gaps in casualty care in the current period and (2) compare results of the 3 periods to provide a model of implementing tourniquet use locally to civilian emergency medical systems.

Correlation of β-human chorionic gonadotropin with ultrasound diagnosis of ectopic pregnancy in the ED

Amy J. Bloch, Scott A. Bloch, Matthew Lyon — 2013-03-13

Women with ectopic pregnancies tend to have lower β-human chorionic gonadotropin (β-hCG) levels than women with intrauterine pregnancies (IUP) . Transvaginal ultrasound (TVUS) is capable of detecting IUPs when β-hCG levels are greater than 1500 mIU/mL, the so-called discriminatory zone . When serum β-hCG levels are less than 1500 mIU/mL and no IUP is detected, possibility of ectopic pregnancy or early IUP exists. Because of the discriminatory zone, emergency physicians often opt not to perform ultrasound on patients whose β-hCG level is less than 1500 mIU/mL. Many ectopic pregnancies, however, are detected by emergency TVUS with β-hCG levels less than 1500 mIU/mL .

Gram stain for Vibrio species

Chia-Chang Kuo, Chien-Ming Chao — 2013-03-18

We read with great interest the article by Ryu et al that described a case of necrotizing soft tissue infection caused by Vibrio vulnificus, which was initially identified as Pseudomonas aeruginosa. In that report, a bacterial culture of surgical specimens was reported as P aeruginosa; however, its associated antibiotic susceptibility pattern was unusual. Therefore, a retest of the bacterium was performed, and finally, V vulnificus was confirmed by 16S rRNA. In addition to conventional laboratory or advanced molecular methods for the identification of bacterium, we would like to remind the readers to not overlook the importance of Gram stain, which is a relative rapid and easy procedure for diagnosis. Especially for Vibrio species, its morphology should be that of a curved gram-negative rod on the microscopic examination. Based on the characteristics of Vibrio species' morphology, a Gram stain can promptly help differentiate Vibrio species from Pseudomonas species. Therefore, if the Gram stain is done for a surgical specimen or the clinical isolate from a culture colony, Pseudomonas species can be easily excluded and Vibrio species may be considered first. Most importantly, we would like to emphasize the clinical significance of Gram stain as a diagnostic tool for bacterial infection.

Perceptions about time for normalization of international normalized ratio in patients requiring acute warfarin reversal when using fresh-frozen plasma

2013-03-13

The use of fresh-frozen plasma (FFP) is the mainstay to urgent reversal of anticoagulation []. We used an online, direct-to-provider survey to characterize the perceived times required to administer FFP and urgently normalize the international normalized ratio (INR) in those settings.

Hyperkalemia-induced pacemaker dysfunction

2013-03-13

We read with great interest the article by Muck et al . The authors reported a very interesting case surviving extreme hyperkalemia. We also recently had a case of hyperkalemia-induced pacemaker dysfunction manifested as failure of pacemaker capture and leading to unnecessary invasive pacemaker evaluation.

Reply to: Brain computed tomographic scan findings in acute opium overdose patients

Sankalp Gokhale, — 2013-03-01

I read with great interest a recent article published by Farkhondeh Jamshidi et al—“Brain computed tomographic scan findings in acute opium overdose patients” in the recent issue of American Journal of Emergency Medicine (volume 31, issue 1, January 2013, Pages 50-53) .

How can we diagnose pure opium overdose cases in retrospective medical chart reviews?

Hossein Sanaei-Zadeh — 2013-03-07

We are grateful for the interest in our article “Brain computed tomographic scan findings in acute opium overdose patients” . In retrospective studies, such as ours, some limitations are inevitable. For instance, exclusion of the multidrug exposures based on the history is one of them that has been mentioned as the most important limitation of our study in the “Discussion.” Regarding the use of toxicology screening for exclusion of other substances of abuse, it should be mentioned that each drug of abuse screening test may exhibit a different cross-reactivity profile. Depending on this profile, drug abusers may have false-positive or false-negative results . Furthermore, in drug screens, some substances of abuse cross-react with other medications . Therefore, with these limitations, the results of such screening tests may sometimes create confusion except for when they are confirmed by retesting using a nonimmunologic test . In addition, the major problem with opiates is that several opiates are metabolized into each other. For example, morphine is a metabolite of codeine and heroin as well as a constituent of opium. So, heroin exposure cannot be distinguished from opium exposures using such screening tests. In addition, synthetic opioids are often not detected by these tests. With respect to the aforementioned points, even if few patients' samples were sent to perform toxicology screening tests and reports of their results were available in the files, these results would not be valuable for the inclusion or exclusion of the cases. However, attention to the following points shows that our results and conclusion are reliable: (1) Opium overdose is very common in our country . (2) In addition to the history, diagnosis of the isolated opium overdose cases in medical charts has been made based on clinical manifestations that are different from overdose with other non-opioid abused drugs. (3) Cocaine and crack cocaine abuse is rare in Iran. (4) Although acute overdose by amphetamines, methamphetamines, and ecstasy is not so uncommon in our country , of the most common—if any—findings of their overdose similar to that of cocaine are subarachnoid or intracerebral hemorrhages, which were not detected in none of our cases . (5) Cannabis is one of the most commonly abused drugs in our community . However, the relation of ischemic strokes with its overdose has not yet been established . (6) In addition to other exclusion criteria that have been mentioned in our article, some cases of previously diagnosed structural changes on brain computed tomographic scan were also found that were not included. These were cerebral palsy, arteriovenous malformations, cerebral atrophies, previous surgeries on the brain, brain tumors, and previous cerebrovascular accidents. Thus, we believe that, in communities with high frequency of opium abuse, our results can surely be applicable in the clinical practice.

Scientific publication in emergency medicine from mainland China, Hong Kong, and Taiwan: a 10-year survey of the literature

Hong Cui, Qin-qin Gao, Ling-ling Gao — 2013-03-13

The scientific publications in emergency medicine by Chinese authors were not reported. We therefore intended to reveal the contribution of Chinese authors in the major regions of China—mainland China, Hong Kong, and Taiwan—to the research in the field of emergency medicine.

Factors associated with survival after in-hospital cardiac arrest in Hong Kong

Jacky C. Chan, T.W. Wong, Colin A. Graham — 2013-03-13

The rate of return of spontaneous circulation (ROSC) for in-hospital cardiac arrest (IHCA) is 15% to 60% and survival to discharge is 15% to 20% . Monitoring for ventricular fibrillation or ventricular tachycardia (VF/VT) , early cardiopulmonary resuscitation (CPR) and defibrillation and medical emergency teams can significantly improve cardiac arrest outcomes. This study investigated the clinical variables associated with ROSC and survival to discharge after IHCA in Hong Kong.

Availability of intravenous lipid emulsion therapy on endosulfan-induced cardiovascular collapse

Hyung Jun Moon, Jung Won Lee — 2013-03-20

Acute Endosulfan poisoning is associated with a high mortality rate in humans, and can exceed 30% . Prophylactic anticonvulsant therapy for symptomatic patients and aggressive treatment for seizures may limit morbidity, but, no effective antidote is available . However, endosulfan poisoning is often completely reversible with the appropriate management . Intravenous lipid emulsion (ILE) may be a useful in treatment of lipophilic medication overdoses as an adjunct to antidotal therapy . We believe that this is its first reported use in endosulfan toxicity.

Identification of highly concentrated dextrose solution (50% dextrose) extravasation and treatment—a clinical report

Sarah L. Lawson, William Brady, Ahmed Mahmoud — 2013-04-19

Treatment for significant hypoglycemia includes administration of dextrose containing agents, including 50% dextrose (D50%W) intravenously. Significant extravasation of D50%W can lead to complications, including skin and soft tissue injury, loss of limb, or death. The aim of this case report, using an interdisciplinary team approach, explores extravasation protocols as well as literature review, is to provide information about the proper use of hyaluronidase in patients with D50%W extravasations. A 46-year-old African American man presented to the emergency department (ED) after blood glucose level was initially 13 mg/dL. Emergency medical service established a large bore intravenous (IV) line in the right antecubital vein and administered a total of 50 g of D50%W. Upon arrival to the ED, the patient's level of consciousness had significantly improved. After arrival to the ED, the patient started complaining of pain in his right arm, near the site of the IV line insertion. On inspection, the IV site was grossly infiltrated. Hospital protocols for hyperosmolar infiltration were used. Extravasation is a common medical complication of infused medications and needs to be properly identified and treated. The multitude of skills from nursing, medicine, and pharmacy ensures that extravasation is managed appropriately and effectively to ensure safety to patients. Recognition, communication, and awareness of the institutional guidelines on how to treat infiltration and extravasation should be encouraged in all ED and intensive care unit medical personnel who deal with a variety of infusions and IV medications that have serious implications if not treated correctly.

Central scotoma without prodromal illness caused by Bartonella henselae neuroretinitis

Jessica Ann Best, Brian Price — 2013-03-07

This case report describes Bartonella henselae neuroretinitis in a 26-year-old woman who presented to the emergency department with unilateral central scotoma and no prodromal symptoms, a unique presentation of this disease. B henselae, a gram-negative bacteria, is the cause of cat scratch disease. Cat scratch disease (CSD) is a self-limiting illness, which typically presents with regional lymphadenopathy, fever, and small skin lesions in association with a cat scratch or bite. The most common ocular manifestations of cat scratch disease are Parinaud oculoglandular syndrome and neuroretinitis. All prior reported cases of CSD neuroretinitis presented with prodromal symptoms, not vision loss alone.

Ischemic stroke presenting as fluctuating focal weakness in an otherwise healthy young man

Melanie J. Lippmann, Adam H. Miller — 2013-03-13

A 32-year-old man presented to our emergency department (ED) with no complaints after paramedics responded to a fall. Medics noted left-sided weakness on scene. Symptoms were initially absent in the ED, although later recurred, and included dramatically waxing and waning focal weakness. An acute middle cerebral artery ischemic stroke was diagnosed, and tissue plasminogen activator was administered. Despite a fluctuating course of symptoms, our patient ultimately achieved a complete recovery.

Cerebral venous sinus thrombosis as an initial manifestation of primary antiphospholipid syndrome

Chia-Lin Tsai, Dueng-Yuan Hueng, Wen-Long Tsao, Jiann-Chyun Lin — 2013-04-19

Cerebral venous sinus thrombosis is a rare neurologic manifestation of antiphospholipid syndrome. We report a case of a 49-year-old woman who presented to the emergency department with recurrent episodes of transient clumsiness of the left upper extremity. The results of unenhanced brain computed tomography and electroencephalography were unremarkable. Serial neuroimages revealed superior sagittal sinus thrombosis. Thrombophilia screen disclosed positive lupus anticoagulant. In this case report, we aim to emphasize the significance of recognizing an unusual presentation of antiphospholipid syndrome.

Do we need to wait longer for cardiac arrest survivor to wake up in hypothermia era?

Min-Shan Tsai, Jo-Yu Chen, Wen-Jone Chen, Chien-Hua Huang — 2013-01-28

Before the era of therapeutic hypothermia, a practice parameter including absent or extensor motor response at day 3 and the presence of myoclonus status epilepticus within 24 hours was used to assist prognostication of poor neurologic outcomes. There are conflicting results concerning whether hypothermia influences the reliability of the predictors and the accurate predictors and optimal timing for assessing neurologic recovery are largely unknown. Several prognostic indicators other than guidelines are also applied to help determining prognosis, including electroencephalogram, cerebral computed tomographic scan, and cerebral perfusion scintigraphy single-photon emission computed tomographic scan. Here, we present a cardiac arrest survivor treated with therapeutic hypothermia waked up finally on the 13th day, although clinical and laboratory examinations after return of spontaneous circulation all indicated poor neurologic prognosis. However, life support was reported to be withdrawn within 3 to 5 days in 25% to 50% cardiac arrest survivors treated with hypothermia when grave prognosis was predicted. The clinical course of the patient raises some important questions concerning the accuracy of current predictors, the optimal observation period for neurologic recovery, and the appropriate timing to determine withdrawal of life support in cardiac arrest victims receiving therapeutic hypothermia.

Bilateral thalamic infarct as a diagnosed conversion disorder

Ugur Lok, Oner Yalin, Ramazan Odes, Selim Bozkurt, Umut Gulacti — 2013-02-11

Bilateral thalamic infarcts are an uncommon type of cerebral infarct. Bilateral paramedian thalamic infarctions may lead to a severe impairment of consciousness. The sudden onset of a lethargy or comatose state, in the absence of motor deficits, easily evokes the idea of a subarachnoid hemorrhage. Other patients present with behavior changes, disorientation in space and time, memory loss, or thought disorders. We believe that bilateral thalamic infarction is often missed in emergency department (ED) in relatively young patients, especially when magnetic resonance imaging is not performed. In these cases, the patient can be discharged with various psychiatric diagnoses. We suggest that bilateral thalamic infarct should be considered in patients in the ED with new diagnoses of conversion disorder.

Adult female with hematemesis—Dieulafoy lesion

Mansour Jammal, Boris Khodorkovsky, Mark Raden, Barry Hahn — 2013-04-22

A 40-year-old healthy woman presented to the emergency department with a complaint of intermittent hematemesis, despite the absence of usual factors associated with upper gastrointestinal bleeding (ie, nonsteroidal anti-inflammatory drugs, alcoholism, etc). The patient was diagnosed with a Dieulafoy lesion. This is an uncommon finding, which clinicians must be familiar with and maintain in the differential diagnosis because the consequences of this disease process are grave. It is vital to properly diagnose this condition and be familiar with the treatment.

Takotsubo cardiomyopathy mid ventricle variant and cardiac arrest: chicken or the egg?

Kuljit Singh, Ajay K. Parsaik, Christopher J. Zeitz — 2013-02-11

Takotsubo cardiomyopathy (TTC) is uncommon emergency condition usually precipitated by emotional or physical stress and is characterized by near-normal coronary arteries and regional wall motion abnormalities that extend beyond a single coronary vascular territory. Variants of TTC include classic apical ballooning syndrome and less commonly, mid, basal, and biventricular variants. Cardiac arrest is an uncommon complication of TTC. In the convalescence phase of TTC, prolonged QTc interval may cause cardiac arrest, but the reason for cardiac arrest in the acute phase when QTc interval is normal is unclear. We report 3 cases of mid ventricular TTC, with out-of-hospital cardiac arrest as the presenting feature. All 3 patients had normal QTc interval and were found to have normal coronary arteries on cardiac catheterization at presentation. Mid ventricular TTC was confirmed on contrast left ventriculography and echocardiography. Cardiac arrest myocarditis was ruled out by myocardial biopsy in 2 deceased patients and by cardiac magnetic resonance imaging in the one who survived.

Low-impact trauma causing acute compartment syndrome of the lower extremities

Kristen Aliano, Salil Gulati, Steve Stavrides, Thomas Davenport, George Hines — 2013-03-07

Compartment syndrome usually occurs in the muscles of an extremity as a consequence of trauma or reperfusion. However, it can also occur from minor injuries with resulting hematoma. We reviewed the charts of 5 individuals who presented to the emergency department after minimal or no known trauma and were ultimately diagnosed with acute compartment syndrome. None sustained fractures, and 2 had documented muscle tears. All patients were found to have hematomas in the affected compartment at the time of surgery. Low-impact trauma can cause acute compartment syndrome in the lower extremities. These cases could be the result of muscle hemorrhage and subsequent hematoma formation, rather than muscle swelling itself. Anticoagulation therapy can increase the risk of hemorrhage.

Rescue thrombolysis in the treatment of cardiac shock and acute stroke

Sukru Akyuz, Mustafa Azmi Sungur, Cevdet Donmez, Aylin Sungur, Nese Cam — 2013-04-19

The patients with ST-elevation myocardial infarction are primarily managed with percutaneous coronary intervention (PCI) or thrombolysis. It is well accepted that rescue PCI should be implemented in case of unsuccessful thrombolysis. However, the reverse, rescue thrombolysis, that is, administering of thrombolytic therapy in a patient in whom primary PCI fails, is not well defined. There are no available data about rescue thrombolysis so far. We represent a 43-year-old male patient with Buerger disease (thromboangiitis obliterans) who was admitted to our emergency department for cardiac shock related to inferior and right ventricular ST-elevation myocardial infarction. He was found to have occlusion of both right coronary artery and left anterior descending artery and managed with rescue thrombolysis. It was subsequently recognized that he had concurrent stroke caused by posterior cerebral artery (PCA) occlusion and improved with thrombolysis. It is reported for the first time that rescue thrombolysis has been put into practice and yielded great result after unsuccessful primary PCI.

A different reason for cerebrovascular disease

Ozlem Bilir, Gokhan Ersunan, Asım Kalkan, Tuna Ozmen, Yahya Yigit — 2013-02-11

Bee stings are commonly encountered worldwide. Various manifestations after a bee sting have been described. Local reactions are common. Unusually, manifestations such as vomiting, diarrhea, dyspnea, generalized edema, acute renal failure, hypotension, and collapse may occur. Rarely, vasculitis, serum sickness, neuritis, and encephalitis have been described, which generally develop days to weeks after a sting. We report a case of a 35-year-old man who developed neurologic deficit 6 hours after a bee sting, which was confirmed to be left parietooccipital infarction on magnetic resonance imaging scan. We report this case due to its rarity.

Survival after prolonged resuscitation from cardiac arrest due to diabetic ketoacidosis using extracorporeal life support

Toru Hifumi, Nobuaki Kiriu, Hiroshi Kato, Junichi Inoue, Yuichi Koido — 2013-03-04

Management of cardiac arrest due to severe diabetic ketoacidosis (DKA) using bicarbonate therapy and extracorporeal life support (ECLS) remains controversial. We report a case of a 24-year-old man with insulin-dependent type 1 diabetes mellitus who survived without any neurologic complications after prolonged ECLS (including fluid resuscitation and insulin but no aggressive bicarbonate) for cardiac arrest due to severe DKA. In post-DKA cardiac arrest, insulin and fluid resuscitation is the mainstay of treatment, but ECLS should be considered when prolonged cardiac arrest is expected.

Complete resolution of a solitary pontine abscess in a patient with dental caries

Ming-Hua Chen, Hung-Wen Kao, Chun-An Cheng — 2013-02-11

A solitary brainstem abscess is a rare fatal intracranial infection, which can be mistaken for an acute stroke complicated with a systemic infection. Dental caries without abscess formation can be a possible source of infection. Herein, we describe the case of a 59-year-old man with dental caries who presented with a 4-day history of progressive dizziness, double vision, gait ataxia, emesis, and left facial and body numbness. Fever, suboccipital headache, and difficulties in urinating and defecating were noted on admission. Acute brainstem infarction and suspected aspiration pneumonia were then diagnosed. Magnetic resonance spectroscopy and diffusion-weighted imaging demonstrated a solitary pontine abscess. The neurologic deficits continued improvement after he completed 8 weeks of intravenous antibiotics. The successful nonsurgical treatment of the brainstem abscess in this case was based on high clinical suspicion, early diagnosis, and early combination of corticosteroids and broad spectrum antibiotics.

Endotoxin adsorption by polymyxin B column or intraaortic balloon pumping use for severe septic cardiomyopathy

2013-02-11

Septic patients often have low cardiac output. Some of them present severe cardiac dysfunction such as septic cardiomyopathy. However, no well-known and effective treatment for septic cardiomyopathy exists. The effect of endotoxin adsorption by polymyxin B–immobilized fiber column–direct hemoperfusion (PMX-DHP) and intraaortic balloon pumping (IABP) for septic shock remains uncertain. We experienced 2 very contrastive case reports of severe septic cardiomyopathy. We experienced 2 cases of severe septic cardiomyopathy with refractory shock. Case 1 with colon perforation presented refractory shock 6 hours after PMX-DHP, and IABP immediately improved her hemodynamics. In contrast, IABP had no effect at all in case 2 with viral enteritis, but PMX-DHP improved her blood pressure and stroke volume markedly. The probability of impaired coronary microcirculation and relative bradycardia is the least required conditions for IABP use in severe septic cardiomyopathy. Meanwhile, PMX-DHP could be a good option for septic cardiomyopathy because of its fewer complications.

Worsening Wenckebach after calcium gluconate injection: not uncommon but frequently missed diagnosis

Ali Abdul Jabbar, Abdul Wase — 2013-03-04

The objective of the study is to demonstrate a common etiology of hyperkalemia and illustrate a potential iatrogenic errors in treatment. A 69-year-old woman admitted for worsening nausea and vomiting for 2 days. The patient has a history of end-stage renal disease on hemodialysis and missed her treatment for over a week. Physical examination was unremarkable. Initial laboratories showed a high anion gap metabolic acidosis with potassium level of 6.4 mmol/dL.

Deep sedation with sevoflurane insufflated via a nasal cannula in uncooperative child undergoing the repair of dental injury

Seung-Oh Kim, Young-Jae Kim, Yong-Seo Koo, Teo Jeon Shin — 2013-02-11

Sevoflurane, a potent volatile anesthetic, has been attempted to be used for procedural sedation. Because of lack of a commercially available sedation apparatus for sevoflurane administration, anesthetic gas delivery apparatus should be connected to general anesthetic machine for delivering sevoflurane gas. In this case, deep sedation was maintained during treatment of dental injuries involving the upper lip and incisor by sevoflurane insufflations via a nasal cannula. Especially, this may be advantageous in treating dental injuries involving upper lip and maxillary anterior teeth because the treatment is not disturbed during sevoflurane insufflations via a nasal cannula.

Incomplete Kawasaki disease

Margarita M. Miller, Adam H. Miller — 2013-03-07

This is a report of a 4-year-old Hispanic boy who presented with skin changes to the lips and oral cavity, a generalized rash, edema of hands and feet, and peeling of the periungual areas of the fingers as well as to the groin and perianal areas. Fourteen days earlier, his 19-month-old brother was diagnosed and treated for Kawasaki disease. Upon laboratory investigation, our patient was found to have an elevated sedimentation rate, C-reactive protein, and serum γ-glutamyl transferase. Infectious disease and cardiology consultations subsequently diagnosed and treated our patient for incomplete Kawasaki disease.

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2013-05-01

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2013-05-01

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2013-05-01

American Journal of Emergency Medicine

Role of inferior vena cava and right ventricular diameter in assessment of volume status: a comparative study: Ultrasound and hypovolemia

Ulinastatin improved cardiac dysfunction after cardiac arrest in New Zealand rabbits

A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding

Differentiation of exudate from transudate ascites based on the dipstick values of protein, glucose, and pH

Atypical presentations of dengue disease in the elderly visiting the ED

Factors associated with use of emergency medical services in patients with acute stroke

Evaluating the HATCH score for predicting progression to sustained atrial fibrillation in ED patients with new atrial fibrillation

An after-action review tool for EDs: learning from mass casualty incidents

Swimming injuries treated in US EDs: 1990 to 2008

Ultrasound guidance for radial arterial puncture: a randomized controlled trial

Cytokine markers as predictors of type of respiratory infection in patients during the influenza season

Impact of ED management on hospital quality measures: the negative case of atrial fibrillation

Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED

Predicting the hyperglycemic crisis death (PHD) score: a new decision rule for emergency and critical care

Don't get sick on the weekend: an evaluation of the weekend effect on mortality for patients visiting US EDs

Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older

Mass-gathering medicine: a descriptive analysis of a range of mass-gathering event types

Effective analgesia with low-dose ketamine and reduced dose hydromorphone in ED patients with severe pain

A descriptive study of myoclonus associated with etomidate procedural sedation in the ED

Risk factors for ED use among homeless veterans

ED management of patients with eating disorders

Electrocardiographic implications of the prolonged QT interval

“Relaxed” reference formatting: a digital dividend for authors

Comment on “A new electrocardiogram finding for massive pulmonary embolism: ST elevation in lead aVR with ST depression in leads I and V4 to V6”

Performance improvement in emergency tourniquet use during the Baghdad surge

Correlation of β-human chorionic gonadotropin with ultrasound diagnosis of ectopic pregnancy in the ED

Gram stain for Vibrio species

Perceptions about time for normalization of international normalized ratio in patients requiring acute warfarin reversal when using fresh-frozen plasma

Hyperkalemia-induced pacemaker dysfunction

Reply to: Brain computed tomographic scan findings in acute opium overdose patients

How can we diagnose pure opium overdose cases in retrospective medical chart reviews?

Scientific publication in emergency medicine from mainland China, Hong Kong, and Taiwan: a 10-year survey of the literature

Factors associated with survival after in-hospital cardiac arrest in Hong Kong

Availability of intravenous lipid emulsion therapy on endosulfan-induced cardiovascular collapse

Identification of highly concentrated dextrose solution (50% dextrose) extravasation and treatment—a clinical report

Central scotoma without prodromal illness caused by Bartonella henselae neuroretinitis

Ischemic stroke presenting as fluctuating focal weakness in an otherwise healthy young man

Cerebral venous sinus thrombosis as an initial manifestation of primary antiphospholipid syndrome

Do we need to wait longer for cardiac arrest survivor to wake up in hypothermia era?

Bilateral thalamic infarct as a diagnosed conversion disorder

Adult female with hematemesis—Dieulafoy lesion

Takotsubo cardiomyopathy mid ventricle variant and cardiac arrest: chicken or the egg?

Low-impact trauma causing acute compartment syndrome of the lower extremities

Rescue thrombolysis in the treatment of cardiac shock and acute stroke

A different reason for cerebrovascular disease

Survival after prolonged resuscitation from cardiac arrest due to diabetic ketoacidosis using extracorporeal life support

Complete resolution of a solitary pontine abscess in a patient with dental caries

Endotoxin adsorption by polymyxin B column or intraaortic balloon pumping use for severe septic cardiomyopathy

Worsening Wenckebach after calcium gluconate injection: not uncommon but frequently missed diagnosis

Deep sedation with sevoflurane insufflated via a nasal cannula in uncooperative child undergoing the repair of dental injury

Incomplete Kawasaki disease

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