International Journal of Emergency Medicine最新文献

Introduction and aim: External validations of the Good Outcome Following Attempted Resuscitation (GO-FAR) score have been in populations where Do Not Attempt Resuscitation (DNAR) is practised. We aim to externally validate the GO-FAR score in a population without a DNAR order.

Methods: We studied patients ≥ 18 years old who had an In-hospital cardiac arrest (IHCA) with known outcomes at Al Ain Hospital from January 2017 to December 2019, excluding those who died in the emergency department. Studied variables included demography, location, response time, code duration, initial rhythm, primary diagnosis, admission vital signs, GO FAR score variables, discharge status, and functional outcomes as determined by the cerebral performance category score ranging from 1 (good cerebral performance) to 5 (brain death).

Results: 366 patients were studied; 66.7% were males. The median (IQR) age was 70 (55-81) years. Cardiac and respiratory causes were the primary diagnoses in 89 (24.6%) and 67 (18.5%), respectively. IHCA occurred in critical areas such as the intensive care unit, high dependency unit and coronary care unit in 206 (80.8%) patients. The majority, 308 (91.8%), had a non-shockable rhythm, and a return of spontaneous circulation was achieved in 159 (43.4%) of the patients. Thirty-one (8.5%) patients survived to hospital discharge, and 20 (5.5%) patients had cerebral performance category scores of 1 and 2. The area under the curve of the ROC for survival to discharge with good functional outcome was 0.74 (95% CI 0.59-0.88). The best cut-off point for predicting survival with a good neurological outcome was a GO-FAR score of < 4, having a sensitivity of 0.81, a specificity of 0.7, a positive likelihood ratio of 2.7 and a negative likelihood ratio of 0.27.

Conclusions: A GO-FAR score of less than 4 predicts survival with a good neurological outcome in a healthcare system with an all-inclusive patient population with no DNAR practice.

Background: Tetanus is a clinical rarity due to the successful globally adopted childhood vaccination programme. The rising elderly population in the United Kingdom creates a subset of individuals whom are prone to develop Tetanus as they preceded this vaccination drive. A 76 year old Caucasian lady presented with a soil contaminated laceration injury on her knee following a fall. Though she received urgent assessment and wound care, the relevance of the injury in the backdrop of her age was not appreciated and her tetanus post exposure prophylaxis was overlooked. She readmitted seeking further management 1 week later with an infected wound with Trismus and clinical features favoring Generalized tetanus. During her stay she developed Takotsubo-cardiomyopathy with congestive cardiac failure and required prolonged care in the intensive unit with mechanical ventilation and rehabilitation before being discharged home.

Conclusion: First contact physicians should have a greater appreciation of the types of injuries and at-risk individuals who are more prone to develop tetanus upon exposure to ensure early and appropriate identification. There should be greater situational awareness with regard to the elderly in view of their heightened risk of development of tetanus specially those born before the vaccination drive. Knowledge regarding post exposure prophylaxis measures for tetanus should be regularly updated using local guidance to ensure awareness, so as to despite its rarity Tetanus remains an adequately appreciated disease.

Introduction: Cardiac amyloidosis is a rarely reported and potentially fatal variant of the systemic disease. Its early diagnosis could potentially lead to significantly improved clinical outcomes.

Case presentation: A 56-year-old female presented with dyspnea and palpitations. Her physical exam and non-invasive evaluation with cardiac magnetic resonance imaging (CMRI) revealed restrictive cardiomyopathy, and the bone marrow biopsy results showed systemic amyloidosis.

Discussion: The diagnosis of cardiac amyloidosis is not always straightforward, and delay can cause the progression of the disease and an increased risk of morbidity and mortality. Electrocardiograms, echocardiograms, cardiac magnetic resonance imaging, and histopathologic evaluation are the main methods for diagnosing cardiac amyloidosis. The treatment consists of controlling heart failure symptoms and disease-modifying interventions, including medical and surgical therapeutic methods.

Clinical learning point (conclusion): Cardiac involvement is the main cause of death in systemic amyloidosis. Early suspicion, diagnosis, and treatment are crucial in improving patients' survival. CMRI can play an essential role in the diagnosis of cardiac Amyloidosis. A graphical abstract is provided for visual summary.

Background: The significance of computed tomography (CT)-based volume measurement of the inferior vena cava (IVC) in the treatment and prognosis of trauma patients is not yet fully understood. The conflicting results that have been reported may be attributable to differences in injury severity and the use of different measurement methods, including IVC index and volumetry. The purpose of this study was to determine the relationship between IVC volume and red blood cell (RBC) transfusion and mortality in intubated trauma patients who were stable enough for initial CT imaging.

Methods: A retrospective analysis was conducted on all consecutive trauma patients who underwent emergency tracheal intubation and mechanical ventilation before initial whole-body CT imaging at a level-1 trauma center over a 12-year period (2008-2019). The IVC volume was determined on initial trauma CT and included in multivariable models with demographic and diagnostic data. Associations of overall RBC transfusion, massive transfusion, 24-h mortality, and 30-day mortality were assessed using logistic regression analyses and Cox proportional hazard models.

Results: A total of 438 patients (75.3% male) with a median age of 50 years, and a median injury severity score (ISS) of 26 points were included in the analysis. Most of the patients (97.5%) had suffered from blunt trauma mechanisms. Median IVC volume was 36.25 cm³, and RBC transfusion and massive transfusion were performed in 197 and 90 patients, respectively. The 24-h and 30-day mortality rates were 7.3% and 23.3%, respectively. VCI volume was found to be independently associated with the necessity of RBC transfusion and 24-h mortality (OR 0.98, 95% CI 0.96-0.99, p = 0.01 and HR 0.96, 95% CI 0.93-0.99, p = 0.025, respectively), while associations with massive transfusion and 30-day mortality were not statistically significant in multivariable analyses.

Conclusion: Initial IVC volume may serve as a predictor of patients at risk for overall RBC transfusion requirements and 24-h mortality, suggesting the possibility of its diagnostic efficacy in short-term outcomes. Further studies are needed to confirm these findings.

Background: Chest pain is a frequent cause of health care contacts. We examined the prehospital management, in-hospital discharge diagnoses, and mortality of patients calling a non-emergency and emergency medical service with chest pain.

Methods: The Copenhagen Emergency Medical Services (EMS) consists of a non-emergency medical helpline (calls to 1813) and emergency medical service (1-1-2 calls). We included all calls to the Copenhagen EMS with a primary complaint of chest pain from 2014 to 2018 in Copenhagen, Denmark. The outcomes were: emergency response (ambulance dispatch, other transports/self-transport/home visits, self-care, and unknown/cancelled response), in-hospital diagnosis within 7 days after the call (cardiovascular, pulmonary, or other non-cardiovascular/pulmonary) and 30-day mortality.

Results: Among 4,834,071 calls, 91,671 were registered with chest pain at the Copenhagen EMS. The first call for each patient was kept for analysis (n = 66,762). In total, 91.4% were referred to the hospital, 75.8% (n = 50,627) received an ambulance and 15.6% (n = 10,383) received other transport/self-transport/home visits. Overall, 26.9% (n = 17,937) were diagnosed with a cardiovascular disease, 5.2% (n = 3,490) a pulmonary disease, 52.8% (n = 35.242) other non-cardiovascular/pulmonary disease, and 15.1% (n = 10,093) received no diagnosis. Among ambulance-transported patients, the prevalence of cardiovascular discharge diagnoses was higher (32.1%) and fewer received no diagnosis (11.0%). Cardiovascular disease was less prevalent among patients not transported by ambulance and patients not referred to hospital at all (2-13.4%) and in patients ≤ 40 years of age (< 10%). The 30-day mortality was below 5% regardless of diagnosis (0.6-4%), and 65,704 (98.4%) were still alive 30 days later.

Conclusion: Nearly all patients calling with chest pain were referred for treatment. Among ambulance-transported patients, around half of the patients did not have a cardiovascular/pulmonary disease. While current practices appear reasonable, improved differentiation of chest pain patients in telephone consultations could potentially both improve the treatment and management of these patients and reduce the in-hospital burden of non-acute chest pain consultations.

Background: While initial non-shockable (NS) rhythms are often associated with poor prognosis, the conversion to shockable rhythms during cardiopulmonary resuscitation (CPR) can significantly influence survival rates. This retrospective cohort study investigated the impact of rhythm conversion on the return of spontaneous circulation (ROSC) in out-of-hospital cardiac arrest (OHCA) patients.

Methods: The study analyzed data recorded from January 2012 to August 2022 obtained from the Utstein Templates from The Institute of Emergency Medicine of the City of Zagreb. Statistical analysis, including logistic regression, was performed to assess the likelihood of achieving maintained ROSC.

Results: Study included 2791 cases of OHCA with emergency medical service attempts at resuscitation. A total of 74.92% of patients had an initial NS rhythm with a total conversion rate of 18.27%. Factors significantly associated with rhythm conversion were younger age, male sex (74.13%), public place (32.35%) of and witnessed collapse (75.98%), higher adrenaline dose, use of a mechanical compression machine (41.68%), and shorter response interval. There was no significant difference in the occurrence of conversion between the cases with initial asystole and pulseless electrical activity (PEA). However, cases with converted asystole (33.48%) compared to the ones with converted PEA (20.65%) had significantly greater ROSC maintenance (p = 0.006), as well as when compared to cases with sustained PEA (20.93%, p < 0.001). Logistic regression revealed that women with rhythm conversion, lower adrenaline doses, and provided bystander CPR were significantly more likely to achieve ROSC at hospital admission (P < 0.001).

Conclusions: This comprehensive study sheds light on the importance of rhythm conversion in patients with OHCA, with greater ROSC achievement, especially in patients with initial asystole, than in patients with initial PEA.

Background: Pericardiectomy due to constrictive pericarditis is usually safe procedure. There was a rare event of thrombosis after pericardiectomy, which was mainly accounted by low-cardiac-output syndrome.

Case presentation: Here, we report the case undergoing pericardiectomy after constrictive pericarditis, with fatal cerebral thrombosis after pericardiectomy confirmed by endovascular mechanical thrombectomy. Even though recanalization was completed and suggestive decompressive craniectomy was in preparation, the patient still died for cerebral hernia due to severe edema. The causes of cerebral thrombosis after pericardiectomy in this case was accounted by the persistence of nonpliable pericardium encasing the left ventricular wall limited local myocardium motor, pro-coagulable state due to thermal transmission during decortication like radiofrequency ablation under the condition of postoperative atrial fibrillation and rapid ventricular rates precipitated the information of mural thrombus in cardiac cavity and migration into the main branch of the aortic arch.

Conclusion: The protocol of prompt aggressive anticoagulation prophylaxis would be vigilantly recommended for the patients undergoing pericardiectomy.

The 'shark-fin' ECG-sign is a rare electrocardiographic pattern seen in ACS, typically associated with poor prognosis. However, its manifestation in acute aortic syndromes remains largely unexplored. Here, we present a case of a patient diagnosed with Ascending Aortic Dissection, who presented to ED with acute chest pain and shark-fin ECG-pattern.

Background: Convexity subarachnoid hemorrhage (cSAH) is an uncommon presentation of subarachnoid bleeding, referring to bleeding more localized to the convexities of the brain. The diagnosis of cerebral venous sinus thrombosis (CVST) can be difficult especially when patients initially present with cSAH. The authors present a case and then discuss the pathophysiology and management.

Case presentation: A 56-year-old woman with a previous history of hypertension and ischemic heart disease presented to the emergency department after experiencing it. Two seizures following a severe headache. The patient's history was negative for recent illnesses, head trauma, history of migraines, smoking, alcohol consumption, or intravenous drug use. The patient was diagnosed with CVST based on magnetic resonance venography (MRV). Genetic studies further identified homozygous mutations in the Prothrombin and MTHFR genes. Anticoagulant therapy was initiated with 60 mg of Enoxaparin twice daily and subsequently transitioned to Warfarin after 48 h continued for 3 months, and then replaced by rivaroxaban.

Conclusions: This study highlights the importance of considering CVST as a cause of SAH, emphasizes the role of advanced imaging in diagnosis, and demonstrates a successful treatment approach using both traditional and direct oral anticoagulants. The insights provided in this article can contribute to improving the management of patients with CVST-related SAH.

Overcrowding is a worldwide problem, and long waiting times are associated with increased morbidity and even mortality of patients regardless of triage classification. Although there are many tools published in the literature that contribute to the reduction of overcrowding, for the Colombian population there are not many tools evaluated to reduce the length of stay of patients in the emergency department. This is a retrospective analytical study that compared whether there was a difference in patient definition time and ED length of stay between a group attended under an early care protocol (PAT) versus the usual protocol. Of the total of 969 patients included it was found that the group attended under the PAT protocol had a shorter definition time than the usual protocol, also the Emergency department length of stay (EDLOS) was significantly lower in the PAT group compared to the usual protocol. The implementation of the PAT protocol performed by emergency physicians allows a faster contact with the patient by the physician, and leads to a significant reduction of EDLOS, contributing to the reduction of overcrowding in the emergency department.