International Journal of Emergency Medicine最新文献

Introduction: Ogilvie's Syndrome (OS) is a rare but serious functional disorder characterized by dilatation of the colon, typically affecting the cecum and right colon, in the absence of any mechanical obstruction.

Case presentation: We present an unusual case of Ogilvie's Syndrome in a 67-year-old female patient following elective dynamic hip screw surgery. She presented with gradual abdominal distention, as well as gas and stool retention. On the ninth postoperative day, abdominal examination revealed significant distention, marked tympanitic sounds upon percussion, diffuse tenderness on palpation, diminished bowel sounds, and moderate abdominal pain. Investigation tools demonstrated gross dilated in colons, up to 92.4 mm at the cecum level by Abdominal CT which, confirming the diagnosis of Ogilvie's Syndrome. The team opted for conservative treatment, including nasogastric tube (NGT) insertion, fasting, and intravenous fluids. Subsequent imaging a few days later indicated a reduction in colonic diameter (cecum measuring 38 mm) and an improvement in the patient's overall condition.

Conclusion: Although Ogilvie's Syndrome is infrequently encountered, clinicians should maintain a high index of suspicion for gas and stool retention following surgical procedures. It is essential to be familiar with diagnostic methods and management protocols for this condition.

This case describes an atypical presentation of isolated posterior ST-segment elevation myocardial infarction (STEMI), who presented with left arm numbness and weakness, mimicking an acute stroke. Diagnosis was confirmed with coronary angiogram showing occlusion in proximal left circumflex artery, as well as rise in troponin. This atypical presentation highlights the importance of maintaining high index of suspicion and casting a wide net of differential diagnoses in initial assessment of patient in the emergency department.

Background: Acid-base disturbances significantly impact cardiac function and prognostic outcomes in cardiac arrest. Previous studies have highlighted the correlation between pH levels from arterial blood gas (ABG) analyses during cardiopulmonary resuscitation (CPR) in out-of-hospital cardiac arrest (OHCA) and survival outcomes. However, ABG measurements are often impractical in resource-limited settings. This study explores the relationship between serum bicarbonate levels and survival outcomes in patients with OHCA.

Methods: This retrospective cohort study examined patients with OHCA who presented at Srinagarind Hospital (Thailand) between 2015 and 2021. We analyzed venous bicarbonate levels and other laboratory markers (Na+, K+, BUN, Creatinine). Demographic and clinical data were extracted from electronic medical records. The primary objective was to assess the association between venous bicarbonate levels and survival and to determine the optimal cutoff values for predicting survival in these patients.

Results: Of the 461 identified patients, 19% survived hospital discharge. Survivors exhibited higher bicarbonate and BUN levels but lower potassium levels. Bicarbonate levels ≥ 12.6 demonstrated a sensitivity of 74% and specificity of 47%, with an 88.44% negative predictive value (NPV) for survival. A sensitivity analysis, which reclassified patients who left against medical advice as non-survivors, revealed that a bicarbonate cutoff of 13.9 mmol/L yielded the best predictive value, with a sensitivity of 93.8% and a specificity of 52.1%. Factors associated with increased survival included BUN ≥ 19.5, bicarbonate ≥ 12.6, private transport, and initial PEA or VT/VF rhythms, while potassium ≥ 5.1 decreased survival likelihood.

Conclusion: Bicarbonate levels, particularly with a threshold greater than 12.6 mmol/L, may be effective prognostic indicators. Other factors influencing survival include BUN, potassium levels, private transport, and initial cardiac rhythm. These insights can help clinicians improve resuscitation strategies and prognosis assessment, especially in resource-limited settings.

Background: Disseminated tuberculosis (TB) presenting as miliary nodules on the gallbladder and liver is extremely rare and poses significant diagnostic challenges. This report describes a case of disseminated TB discovered during emergency laparoscopic cholecystectomy for acute cholecystitis.

Case presentation: A 77-year-old male presented with decreased appetite, weight loss, and fever. Preoperative imaging suggested gallstones and cholecystitis. During surgery, multiple miliary nodules were found on the surfaces of the gallbladder and liver, raising suspicion of metastatic cancer. Intraoperative frozen pathology revealed epithelioid granulomas with necrosis, and postoperative molecular testing confirmed Mycobacterium tuberculosis.

Conclusions: This case highlights the importance of considering TB in the differential diagnosis of intra-abdominal nodules, especially in TB-endemic regions. Intraoperative frozen pathology and molecular diagnostics are crucial for timely and accurate diagnosis.

Background: Diaphragmatic hernias can be congenital or acquired, with trauma being the primary cause of the latter. Both types may have delayed presentations, with abdominal organs protruding into the thoracic cavity, causing symptoms of varying severity. Pregnancy can sometimes precipitate the condition. Tension pneumothorax resulting from bowel perforation into the thorax is exceptionally rare, with only a few cases reported. To the best of the authors knowledge, this is the third documented case of a late-presenting trauma-related diaphragmatic hernia during pregnancy, complicated by tension pneumothorax.

Case presentation: A 30-year-old woman, 29 weeks pregnant, was referred to Semmelweis University emergency department with moderate dyspnea. Initial investigation revealed tension pneumothorax. Chest tube placement released air, pus, and feces. Computer tomography identified a diaphragmatic hernia with bowel incarceration and perforation as the underlying cause. The patient underwent a delayed cesarean section and surgical repair, with a good outcome. A history of thoracic trauma eight years prior was later revealed.

Conclusion: Evaluating pregnant patients with shortness of breath in the emergency department is challenging. Identifying a history of thoracic or abdominal trauma is crucial, as this can raise the suspicion of diaphragmatic hernia, which can present with a wide range of symptoms. Spontaneous tension pneumothorax in pregnant women is extremely rare and requires cautious management. A multidisciplinary approach is crucial for the successful treatment of maternal diaphragmatic hernia.

Aims: Emergency department (ED) revisits within 72 h is a standard quality measure for emergency care but most revisits are managed and discharged. However, a sub-group of revisits are due to clinical deterioration resulting in admissions to higher acuity care or even mortality. We aimed to identify these critical revisits and their associated risk factors. Identification of these factors would allow development of strategies to reduce incidence of post discharge deterioration.

Methods: A retrospective cohort study was conducted on all patients who had a revisit within 72 h of discharge from the ED of a tertiary hospital in Singapore from 2008 to 2020. Deidentified data were extracted from the electronic health records (EHR). We identified critical revisits, defined as a revisit that resulted in death or admission to Intensive Care Unit or High Dependency. These patients were compared to patients who had a revisit that resulted in discharge or admission to general ward. The main outcome was the rate of critical revisit. We also determined the commonest index and critical revisit ED diagnosis as well as factors associated with critical revisits.

Results: Out of 1,057,533 discharges from the ED over the study period, 44,506 (4.2%) had a revisit within 72 h, of which 1321 (0.12%) were critical revisits. Adjusted odds ratios from multivariable logistic regression analysis indicated that higher heart rate, higher mean arterial pressure, and several lab abnormalities were associated with critical revisits. Diagnosis categories at the initial visit with the highest contribution to the likelihood of a critical revisit included "acute cerebrovascular disease" (OR: 38.00, 95%CI: 27.04-53.39), "other gastrointestinal disorders" (OR: 3.10, 95%CI: 2.41-3.99) and "residual codes; unclassified" (OR: 2.69, 95%CI: 2.01-3.60).

Conclusion: Critical revisits after discharge were rare in our study population, most prevalent amongst the elderly with multiple comorbidities. Future research should focus on diagnoses at higher risk of a critical revisit to develop practical approaches to follow up these patients.

Background: Mentorship is vital to foster personal and professional growth. Speed mentoring is a newer model of mentorship that introduces trainees to several potential mentors. The Society for Academic Emergency Medicine (SAEM) hosts a speed mentoring event at its annual meeting. During the COVID-19 pandemic, the annual meeting transitioned to a virtual format. This study compares participants' attitudes towards in-person and virtual speed mentoring.

Methods: Medical students, residents, and faculty mentors completed a biographical sheet to inform pairings and to facilitate discussion. The same anonymous event evaluation was administered to the participants during both the in-person (SAEM19) and virtual speed mentoring event (SAEM21). We assessed whether there were significant differences in viewpoints of participants of the two formats using Fischer's Exact Test for each question by role and performed a thematic analysis on the free-text question.

Results: The response rates for mentors and mentees were 89.6% (43/48) and 77.1% (37/48) for SAEM19, and 76.9% (10/13) and 84.6% (11/13) for SAEM21, respectively. Participants responded similarly to all (p > 0.05) but one question. Mentors were more neutral that the event helped them feel more comfortable around trainees at the conference (p = 0.01). Otherwise, participants indicated the event was enjoyable, planned to participate again, and felt empowered to make further connections outside of the event. Free responses underscored these themes and suggested increasing time per encounter.

Conclusions: Virtual speed mentoring is a feasible and effective alternative to in-person speed mentoring and may be a helpful adjunct to in-person mentoring.

Introduction: Postpartum acute pancreatitis (PAP) is a rare but potentially life-threatening condition that can occur following childbirth. The incidence of PAP is estimated to be between 1 in 1,000 and 1 in 10,000 deliveries, with a significant proportion of cases linked to biliary causes, particularly gallstones and biliary sludge. Prompt diagnosis and comprehensive management are essential to prevent severe complications such as septic shock and peritonitis.

Case presentation: We report the case of a 25-year-old white woman who presented with severe abdominal pain and septic shock 18 days after a cesarean section. Initial management included aggressive fluid resuscitation, broad-spectrum antibiotics, and pain control. Diagnostic imaging and laboratory tests confirmed the presence of biliary obstruction due to gallstones and biliary sludge, leading to acute pancreatitis. An endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the biliary obstructions, followed by a laparoscopic cholecystectomy to prevent recurrence.

Discussion: PAP, while rare, poses significant risks and can lead to serious side effects such as septic shock. Early diagnosis by laboratory workup and imaging is essential. In this instance, gallstones and biliary sludge were found to be the culprit, requiring cholecystectomy and ERCP. ERCP was effective in this patient, despite its controversy in septic patients. The effective management of PAP requires a multidisciplinary approach involving obstetricians, gastroenterologists, surgeons, and critical care specialists.

Conclusion: PAP must be identified and treated as soon as possible. Bile obstruction is a common problem that necessitates prompt imaging and, if necessary, endoscopic or surgical intervention. Delays can be fatal; timing is crucial. To prevent deadly consequences, doctors must be extremely suspicious of postpartum patients presenting with abdominal pain.

Background: Adenocarcinoma of the distal common bile duct (CBD) is a rare and aggressive malignancy that is often diagnosed at an advanced stage owing to nonspecific symptoms and delayed presentation. This case report details the diagnostic and therapeutic challenges associated with distal CBD adenocarcinoma and highlights the need for an effective multidisciplinary approach.

Case presentation: A 54-year-old male with a significant smoking history presented with persistent right upper abdominal pain, dark urine, and scleral jaundice. Imaging studies revealed intrahepatic bile duct dilatation, a mass obstructing the common bile duct, and thickened gallbladder walls. Despite initial antibiotic therapy for suspected cholangitis, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) and subsequently a surgical procedure. The surgical resection of a common bile duct adenocarcinoma with lymphovascular invasion was successful, with subsequent restoration of bile flow through Roux-en-Y hepaticojejunostomy. Histopathological analysis confirmed tumor characteristics and clear surgical margins. Postoperatively, the patient demonstrated significant clinical improvement with normalized bilirubin levels and received appropriate management for his oncologic condition.

Conclusion: This case highlights the diagnostic complexity of distal CBD adenocarcinoma, particularly in patients with delayed symptoms. Multimodal imaging approaches and timely surgical intervention are crucial for effective management of this malignancy. Enhanced awareness of atypical presentations and advancements in targeted therapies holds promise for improving outcomes in such challenging cases.

Purpose: Non-steroidal anti-inflammatory drugs (NSAIDs) are increasingly utilized in trauma patients, particularly those with critical chest trauma who are susceptible to significant blood loss, leading to renal hypoperfusion. Acute kidney injury (AKI) is known to carry a poor prognosis in chest trauma patients. Therefore, investigating the potential association between NSAID use and AKI risk in critical patients with chest trauma is crucial.

Methods: We selected patients admitted to the intensive care unit (ICU) with chest trauma from the Medical Information Mart for Intensive Care III (MIMIC-III) dataset (2001-2012) and the Medical Information Mart for Intensive Care IV (MIMIC-IV) dataset (2013-2019). Propensity score matching (PSM) was used to match patients receiving NSAIDs with those not receiving treatment. Logistic regression was employed to assess the association between different types of NSAIDs and AKI in these patients.

Results: In MIMIC-IV, NSAID use significantly increased the risk of AKI in critical patients with chest trauma (OR 1.99; 95% CI 1.04 to 3.85). Subgroup analysis revealed that aspirin significantly increased AKI risk in both MIMIC-III (OR 1.81; 95% CI 1.02 to 3.2) and MIMIC-IV (OR 2.47; 95% CI 1.26 to 4.85). However, ibuprofen and ketorolac use were not associated with AKI in these patients.

Conclusion: We observed a significant association between aspirin use and an elevated risk of AKI in critical patients with chest trauma. These findings suggest that pain management strategies involving ibuprofen and ketorolac may be more appropriate for this patient population.