International Journal of Emergency Medicine最新文献

Background: Marchiafava-Bignami Disease (MBD) is a rare disorder characterized by demyelination and necrosis of the corpus callosum, with only 300 documented cases worldwide. Chronic alcohol consumption and vitamin B-complex deficiencies are contributing factors. Acute cases may present with a range of neurological symptoms, including seizures and coma. Subacute and chronic forms can lead to interhemispheric disconnection syndrome and progressive dementia.

Case presentation: We present the case of a young male patient's first hospital admission due to an acute decline in conscious level. A detailed history revealed regular alcohol consumption and substandard living conditions. The deterioration in consciousness was attributed to the diagnosis of MBD based on neurological signs, characteristic brain imaging findings, and a history of alcohol use. In addition, a small bowel perforation was also diagnosed. Supportive therapy and thiamine were initiated, and the patient was transferred to surgery for an operation. After two surgeries, the perforation was covered. The patient's level of consciousness showed slight improvement; however, the psychiatrist noted severe cognitive deficits. Ultimately, the patient entered a septic state and passed away.

Conclusion: Acute MBD can potentially cause altered mental state, coma, and death; however, cases can be complicated by other emergency conditions. This case demonstrates the importance of a multidisciplinary approach.

Introduction: Stroke, a leading cause of global morbidity and mortality, disproportionately impacts low and middle-income countries, particularly in sub-Saharan Africa (SSA) which reports the highest stroke burden. The COVID-19 pandemic further complicated this situation, emerging as a significant stroke risk factor. The pandemic also disrupted healthcare systems worldwide, affecting stroke management and care accessibility, and leading to deteriorated conditions in stroke patients upon hospital admission. In this pre/during COVID-19 pandemic analysis of acute stroke cases presenting to a Ugandan hospital, we investigated the relationship between stroke admissions, management and treatment outcomes.

Methods: This was a retrospective medical record review in which we analyzed medical charts of stroke patients admitted to Mbarara Regional Referral Hospital in 2019 (pre-COVID-19) and 2020 (during COVID-19). Socio-demographic data, stroke subtypes, medical history, and physical examination findings were extracted from the hospital records. Data analysis was performed using R-Studio, employing descriptive statistics and inferential analyses to compare stroke characteristics and outcomes across the two periods.

Results: Data from 175 stroke patients was analyzed, with higher admission numbers in 2020 (69.7%), but a slightly higher mortality rate in 2019 as compared to 2020 (22.6% versus 18.9%, p = 0.711). A significant increase in acute ischemic stroke cases was observed in 2020, with no significant differences in stroke severity or functional ability between the two years. Clinical parameters such as admission oxygen saturation, blood sugar, temperature, and Glasgow Coma Scale (GCS) score, along with complications like aspiration pneumonia and infections, correlated with mortality. There was no significant difference in survival probability between pre- and during-pandemic periods. Admission GCS, pulse rate, and aspiration pneumonia were significant predictors of 14-day in-hospital mortality.

Conclusions: The surge in acute ischemic stroke cases during the pandemic highlights the need for robust stroke care systems, especially in high-burden regions like SSA. Some key predictors of mortality are potentially modifiable, suggesting that early intervention and vigilant monitoring of risk parameters could improve survival rates. Findings also highlight the need for tailored care strategies and health system improvements especially during public health emergencies to enhance patient outcomes.

Trial registration: Not Applicable.

Background: Wunderlich syndrome (WS) is a rare condition characterized by spontaneous renal hemorrhage in the absence of obvious trauma or iatrogenic injury. Given that most WS cases are life-threatening and require prompt intervention, timely identification and resolution are essential. Patients with connective tissue diseases (CTDs) account for a small proportion of reported WS cases; however, owing to the specific pathogenic mechanisms and treatments associated with CTDs, these patients exhibit distinctive pathological traits and clinical features in WS.

Case presentation: We present the identification and treatment process of WS in a patient with systemic lupus erythematosus. This patient suffered from sudden abdominal pain and a drastic decline in hemoglobin level accompanied by confusion of consciousness. After the abdominal computerized tomography scan revealed the presence of a renal hematoma, transcatheter arterial embolization was performed on her. Unexpectedly, three days later, the patient had severe anemia and consciousness disorders again. Highly suspecting renal rebleeding, we performed a repeated angiography for the patient. After confirming the bleeding, embolization was carried out again. The renal bleeding stopped, and the patient's hemoglobin level gradually stabilized. Regrettably, this patient ultimately died due to multiple systemic infections.

Conclusions: WS that occurs in CTDs can evolve into critical and severe conditions. Infection, immune complex deposition, thrombocytopenia, abnormal coagulation function, complement activation, autoantibodies production, and glucocorticoid treatment in patients with CTDs are potentially linked to the development of WS. The treatment strategies for WS should be guided by hemodynamic status.

Background: The prevalence of Type 2 Diabetes Mellitus (DM2) is rising, affecting 462 million globally, including 21 million in the U.S. Emergency Department (ED) visits by adults with diabetes in the U.S. increased by 54% from 2012 to 2021 and represent a significant portion of global ED visits. Concurrently, 62% of U.S. adults report lifetime alcohol consumption. This study aimed to correlate AUDIT-C scores to changes in glucose and HbA1c levels in patients with DM2. Previous research has produced mixed results on whether light-to-moderate alcohol use improves or worsens glycemic control. Using a large urban ED dataset, this study seeks to better define this relationship and guide interventions for alcohol use in patients with DM2.

Methods: Data from Long Island Jewish ED (January 2022-October 2023) was analyzed. Patients were included based on an HbA1c ≥ 6.5 or a secondary discharge diagnosis of DM2. AUDIT-C scores were treated as a categorical variable, as no dose-dependent relationship was observed. Statistical analysis was conducted using SPSS 26.

Results: Non-zero AUDIT-C scores were significantly associated with increases in POCT-Blood Glucose, estimated average glucose, and HbA1c. A linear regression model showed an R-value of 0.047 (p < 0.001) for POCT-Blood Glucose in patients with HbA1c ≥ 6.5. Patients with an AUDIT-C score ≥ 1 had higher mean POCT-Blood Glucose (249.72 vs. 226.48, t = 4.240, p < 0.001). Estimated average glucose showed an R-value of 0.045 (p < 0.001), with a mean difference of 11.872 (t = 4.155, p < 0.001). For HbA1c, the R-value was 0.036 (p = 0.004), with higher levels in patients with AUDIT-C ≥ 1 (8.265 vs. 7.904, t = 2.844, p = 0.005). The effects were more pronounced in African-American and Asian-American populations.

Conclusion: Alcohol use, even at moderate levels (AUDIT-C = 1), was associated with higher glucose and HbA1c levels in patients with DM2, particularly among African-American and Asian-American populations. These findings suggest the need for substance use interventions at lower AUDIT-C thresholds and further considerations to mitigate future risk in this population.

Background: Polytrauma is associated with a high mortality rate and often accompanied by coagulopathy. Prothrombin time (PT) is a prognostic factor for mortality in polytrauma patients. The aim was to analyze the time- and severity-dependent role of PT in polytrauma patients related to mortality.

Methods: Patients (≥ 16 years) with an Injury Severity Score ≥ 16 were retrospectively included, yielding 2890 cases after exclusion criteria. PT was measured at admission and 1, 2, 3, 4, 6, 8, 12, 24, and 48 h thereafter, reported as percentage activity of the reference reagence [%]. According to survival status, two groups were formed and compared. Binary logistic regression was used to test PT as an independent predictor for mortality. A closest top-left threshold method served for calculating threshold values between the survivor and non-survivor group. Patients were divided into subgroups according to PT levels and mortality was assessed for each subgroup at each time point.

Results: PT values in the non-survivor group were lower throughout the measuring period (p < 0.05). PT threshold values declined from admission until 2 h afterwards, reaching less than 50%. Already a slightly compromised PT (≤ 70%) represented a significant factor (p < 0.05) for mortality at early and late time points, associated with a rate of more than 20%. In extremis, PT values of ≤ 25% were related to a mortality rate of more than 50% up to four hours after admission.

Conclusion: There are early and significant differences in mortality according to PT values in polytrauma patients (despite resuscitation measures), urging for a fast correction of PT. Time-dependent and stratified referencing may help clinicians estimate the mortality risk and decide upon the extent of surgical care.

Background: In the treatment of small cell lung cancer (SCLC), acute tumor lysis syndrome (ATLS) is one of the oncologic emergencies that requires particular attention. Previous studies have generally indicated that ATLS increases mortality risk during treatm ent. Therefore, early identification of ATLS, along with proactive prevention and symptomatic management, is particularly crucial.

Methods: In this report, we detail the clinical management of a patient with SCLC and multiple metastases who was identified as being at relatively high risk for ATLS due to a large tumor burden and concurrent liver and kidney dysfunction.

Results: Despite rapid tumor progression, the treatment team implemented aggressive hydration and urine alkalinization as pretreatment measures and personalized dose-reduced chemotherapy based on the standard EC regimen. Nevertheless, the patient developed ATLS, which progressed rapidly, and despite intensive treatment, the condition remained irreversible.

Conclusion: This case highlights that in some SCLC patients, pre-chemotherapy evaluation reveals a higher risk for tumor lysis syndrome, and adjusting treatment strategies for these patients requires further investigation. This suggests that managing such high-risk patients in clinical practice requires more cases and optimized treatment strategies to guide management. Therefore, this case is presented to offer insights into this perspective.

Clinical trial number: Not applicable.

Background: Sickle cell disease (SCD) is a common inherited hemoglobinopathy associated with vaso-occlusive events that can mimic pulmonary embolism (PE), leading to the frequent use of computed tomography pulmonary angiography (CTPA). However, trends in CTPA utilization over time remain unclear. This study aims to evaluate temporal trends and recurrent imaging patterns.

Methods: A retrospective cohort study was conducted at Salmaniya Medical Complex, Bahrain, including SCD patients who underwent CTPA for suspected PE between April 15, 2013, and April 15, 2024. Descriptive statistics were used to report the frequency of recurrent scans, whereas linear regression analysis was employed to assess trends in CTPA utilization over the study period.

Results: The study included 1,084 patients (median age: 35 years, 55.7% male) with SCD who underwent a total of 1,934 CTPA scans. CTPA utilization remained stable from 2014 to 2020, averaging 10.0-13.6 scans per month. However, a significant surge was observed post-2020, coinciding with the COVID-19 pandemic, peaking in 2023, with an average of 31.3 scans per month, indicating a 2.9-fold increase (p = 0.03). During the study period, 415 patients (38.3%) underwent recurrent CTPA scans, with one-third (32.5%, n = 276) of these scans occurring within a 6-month interval. Although the PE positivity rate was lower in recurrent scans than in initial scans, the difference was not statistically significant (8.8% vs. 10.5%; p = 0.22).

Conclusions: CTPA utilization among SCD patients remained stable for several years but increased significantly after 2020, coinciding with the COVID-19 pandemic. A substantial proportion of scans were recurrent, with many occurring within a short interval. Moving forward, efforts should focus on mitigating radiation exposure through low-dose protocols and investigating potential factors contributing to the recent increase in scan utilization.

The formation of facial arteriovenous fistula (AVF) directly between the facial artery and vein after trauma is very rare. Compared with intracranial AVF, understanding of this condition is limited. This paper reported the case of a 49-year-old male who had a metallic foreign object impaled on his left neck while weeding 6 months prior to admission. However, 3 months prior to admission, he developed a gradual throbbing of the left neck and swelling on the left side of his face. Auscultation revealed a vascular murmur in front of the mandibular angle on the left side of the face. Digital subtraction angiography (DSA) showed an AVF between the left lateral facial artery and vein, resulting in retrograde blood flow into cavernous sinus though the ophthalmic vein. The authors discuss the management of a traumatic AVF through combined transarterial embolization using coils and Onyx liquid embolic agent. A 3-month follow-up indicated no recurrence of AVF, and the patient had a great recovery with normal-appearing left face and eye. It was the isolated involvement of the facial artery and vein in a post-traumatic setting makes this case particularly instructive. In addition, we summarized the clinical symptoms and treatment of AVF in the face and neck regions.

Introduction: Timely recanalization improves long-term outcomes in acute ischemic stroke (IS) patients, but most patients present outside the therapeutic window. Emergency Medical Services (EMS) can reduce pre-hospital delay and increase the likelihood of recanalization. We aim to determine the characteristic variations amongst suspected acute stroke patients using EMS.

Methods: This retrospective observational study included all suspected acute stroke patients admitted to a national tertiary care hospital in Qatar from January 2014 to September 2020. We evaluated demographics, clinical features, treatment impact, and associated factors in EMS versus non-EMS transported groups.

Results: During the study period, 11,892 patients presented with suspected stroke. Of these, 65.1% used EMS (EMS group) for transportation to the hospital. Median age was comparable between EMS and non-EMS group [52 years; IQR 43-63 vs. 43-62, p < 0.05]. Male to female ratio was 3:1. EMS use in the Qatari population (59.2%) was relatively low. Patients with hemorrhagic stroke (82.4%) had significantly higher EMS use as compared to IS (65.7%) and cerebral venous thrombosis (64.7%); p < 0.001. Symptom onset to ED presentation time was lower in EMS users, with 41.0% arriving within 4.5 h vs. 24.3% in the non-EMS transported group (p < 0.05). Patients with unilateral weakness (66.4%), aphasia (78.2%), neglect (78.2%), dysarthria (68.4%), loss of consciousness (83.3%), and seizures (83.9%) were more likely to use EMS than alternative modes of transportation. Patients attending via EMS had higher rates of thrombolysis than others (82.4% vs. 17.6%; p < 0.001) and a shorter door-to-needle time (56.4 ± 38.2 min vs. 75.7 ± 43.8 min; p < 0.001).

Conclusion: EMS utilization in acute stroke patients was high and was associated with rapid and higher rates of therapeutic intervention. However, younger age, Arab ethnicity, and less obvious stroke symptoms were associated with lower EMS use, emphasizing the need for targeted public health interventions to improve EMS activations.

Background: Percutaneous dilatational tracheostomy (PDT) is a widely performed procedure in intensive care units (ICUs) for patients requiring prolonged mechanical ventilation. Although generally safe, PDT carries risks of complications, some of which may be life-threatening. Foreign body aspiration is a well-known concern, but the iatrogenic migration of procedural components, such as a tracheostomy needle sheath, has received little attention.

Case presentation: We report the case of a male patient with intracerebral hemorrhage (ICH) who underwent a percutaneous dilatational tracheostomy. During the procedure, the sheath of the tracheostomy needle became dislodged and migrated into the tracheobronchial tree. Urgent intervention was required to prevent further complications. Bronchoscopy was promptly performed at the bedside, revealing the foreign body in the right main bronchus. Initial retrieval attempts using biopsy forceps were unsuccessful due to the sheath's positioning. The sheath was eventually maneuvered into the endotracheal tube (ETT) and extracted in a coordinated manner with the simultaneous removal of the ETT and forceps. The tracheostomy tube was then successfully placed under bronchoscopic guidance, and the patient remained stable without further complications.

Conclusion: This case highlights a rare and potentially life-threatening complication of PDT, emphasizing the essential role of bronchoscopy in managing intraprocedural complications. It underscores the importance of procedural expertise and vigilance in ICU settings.