Journal of acute medicine最新文献

The rapid spread of coronavirus disease 2019 (COVID-19) has led to a large number of patients being admitted to hospitals, resulting in a near collapse of the medical system. The shortage of negative pressure isolation rooms and personal protective equipment is a potential problem. It is a pressing challenge to prevent the risk of infection in emergency physicians (EPs) during the endotracheal intubation of patients with COVID-19. We used a large clear plastic bag, cut an opening that covered the patient's head, and created a negative pressure environment inside the plastic bag using the hospital's medical gas pipeline system; thus reducing the amount of virus-containing aerosols leaked out and the risk of infection in the operators performing intubation. The video (http://www.caregiver.com.tw/Article.asp?ID=1258#article) about the detailed preparation of the plastic bag intubation kit (PBIK) has been posted on the website. This technique for safe endotracheal intubation in patients with COVID-19 is being used not only by EPs in Taiwan, but also by physicians and paramedics from other countries. Regarding designing the PBIK, our original intention was to use readily available materials to make tools that can improve the safety of the operators performing the intubations in situations where medical resources are exhausted. However, due to limited time and patients, further research is needed for validation.

Influenza is one of the most common respiratory viral infections, causing annual epidemics of respiratory illnesses characterized by sudden onset of fever, malaise, myalgias, cough, and other respiratory complaints. A spectrum of cardiovascular complications has also been reported in association with influenza infection. Cardiovascular involvement can occur through the direct effects of the virus on the myocardium or through the exacerbation of the existing cardiovascular disease. We report the case of an 86-year-old woman without a history of cardiac disease before admission who developed a transient complete atrioventricular block without myocarditis after acute infection with the influenza A virus.

Angioedema of tongue can be a truly emergency situation and needs rapid evaluation and intervention if airway compromise happens. It is also crucial to recognize the causality of the allergic reaction. Mostly the culprit can be identified if detailed medical regimen and exposure history have been reviewed. A rare case of gabapentin-induced angioedema of tongue is presented.

Lithium intoxication-induced myxedema coma, a rare but dangerous condition of severe hypothyroidism, can be easily misdiagnosed in patients without history of hypothyroidism. The objective of this case report is to describe a lithium-treated patient who presented to emergency department with obtundation and moderate hypothermia and was diagnosed with myxedema coma and lithium toxicity. A 64-year-old female presented to the emergency department with obtundation and hypothermia. The patient had the past history of stage-III chronic kidney disease, bipolar-type schizoaffective disorder, hypertension, and hyperlipidemia, and she had received long-term lithium therapy for the schizoaffective disorder. Bradycardia with hypotension developed after a few hours of admission and thyroid function revealed thyroid-stimulating hormone 53.1 nIU/mL and free T4 (FT4) 0.11 ng/dL, and the serum lithium level was 2.54 mmol/L. Therefore, diagnosis of lithium intoxication-induced myxedema coma was made, and the patient was managed with oral form of levothyroxine (LT4) (loading dose of 400 mcg followed by 100 mcg per day), intensive fluid therapy, empirical antibiotics, mechanical ventilation, and inotropic agents; lithium had been discontinued since admission. The patient weaned from the mechanical ventilation and inotropic support at day 4 of admission and by day 6, the patient's consciousness had fully recovered; on day 9, the serum lithium level was 0.37 mmol/L. The patient's FT4 recovered to the normal range (0.96 ng/dL) on day 15. In patients with no history of hypothyroidism or neck surgery and radiation therapy, lithium intoxication can be the single contributor to myxedema coma, which can be treated with oral form of LT4 as thyroid replacement therapy with instant and intensive supportive care. However, further study is needed to compare the outcomes of the patients with myxedema coma treated by oral and intravenous LT4.

This study involved a simulation of transportation and basic life support on ambulances carrying coronavirus disease 2019 (COVID-19) patients, using a specially modified mannequin. The mannequin used can spew a fluorescent solution from its mouth to simulate the droplets or vomitus made by the patient and can be detected using ultraviolet light illumination. We determined that the most frequently contaminated areas of an ambulance in the driver's cabin are the left front door's outer handle, driver's handler, gear lever, and mat. The most frequently contaminated area in the rear patient's cabin is the rear door, rear door lining, and handle over the roof. The most frequently contaminated areas before the removal of personal protective equipment (PPE) are the lower chest to the belly area, bilateral hands, lower rim of the gown, and shoes. After the removal of PPE, traces of fluorescence were observed over the neck, hands, and legs. We therefore suggest taking a bath immediately after PPE removal.

Backgorund: Previous studies conducted on critical patients in intensive care units have shown that fluid balance disorder (FBD) increases mortality. The purpose of this study is to investigate the effect of FBD on mortality of patients hospitalized in internal medicine ward.

Methods: The present study was designed as an observational study and follow-up period of the patients began in the first 8 hours of admission to the emergency room who had hypervolemia findings in physical examination were included in the fluid balance FB (+) group; those who had any of the dehydration findings were included in FB (-) group, those who had both hypervolemia and dehydration findings were included in FB (mix) group, and those with normal examination findings were included in FB (N) group.

Results: A total of 303 patients, mean age of 66.4 ± 15.9 years, 54.5% male, were included in the study, which covered the period between May 1, 2019 and September 30, 2019. In-hospital, monthly and quarterly cumulative survival rates of the patients were respectively; 91.7 ± 2.7%, 89.2 ± 2.8%, 81.7 ± 3.5% in FB (N) group; 86.3 ± 5.2%, 82.2 ± 5.7%, and 57.8 ± 7.4% in FB (-) group; 70.9 ± 4.4%, 68.1 ±4.4%, and 54.9 ± 4.7% in FB (+) group; 57.6 ± 10.2%, 56.0 ± 9.9%, 44.0 ± 9.9% in FB (mix) group. It was determined that there was an approximately 3-fold increase in both monthly and quarterly mortality risks in those who had FBD compared to those who were not (HR: 3.077 and 3.031, respectively). It was shown with the multivariate Cox regression analyses that this risk increases independently from both preliminary diagnosis, concomitant diseases, vital disorders (30-day and 90-day AHR 2.541 and 2.517, respectively), and from the biochemical disorders (30-day and 90-day AHR 2.132 and 2.124, respectively).

Conclusions: Our study is important in terms of emphasizing the value of physical examination which lost its popularity with the development of technology and many medical instruments, but still simple and cheap.

Background: This study adopts the Situation-Behavior-Impact-Action (SBIA) model to examine the compliance of narrative feedback in the Entrustable Professional Activities (EPAs)-based e-Portfolio system for clinical preceptors in the emergency department of a regional teaching hospital, and analyzes the applicability of its application in emergency clinical training to increase the feasibility of improving the quality of clinical preceptors' feedback content.

Methods: Application of data mining technique to analyze 928 data points was recorded by 14 clinical teachers from April 2017 to May 2019. These data points were narrative feedback from workplace direct observation, which was recorded in the EPAs-based e-Portfolio.

Results: The majority of the narrative feedback consisted of only one component, behavior observed (53.99%) and action suggestion (17.24%). Some feedback consisted of two to three components; which were behavior observed-action suggestion (20.37%) and situation description-behavior observed- action suggestion (1.29%). Only a few feedbacks consisted of all four components: situation description- behavior observed-possible impact-action suggestion (0.75%).

Conclusions: The current narrative feedback is from the basic appearance of SBIA, but there still got room for improvement. The narrative feedback should be given according to SBIA model in order to provide a comprehensive and constructive learning outcome. The narrative feedback recorded in EPAsbased e-Portfolio provides the delay of feedback effect. Thus, multiple feedbacks from various clinical teachers could make the assessments more concrete and outline the authentic clinical condition of the trainees.