Journal of acute medicine最新文献

Background: Non-emergency medicine (EM)-trained physicians comprise a notable proportion of the emergency medicine workforce in Taiwan and many other countries. The possible performance differences at the emergency department (ED) between EM-trained and non-EM-trained physicians have not been evaluated before.

Methods: This retrospective observational study was conducted between August 2018 and July 2020 at a regional hospital in Taiwan. We compared the two physician groups for quality-of-care outcomes, including waiting time, rate of failing to visit patients within the required time, length of ED stay, admission rate, intensive care unit admission rate, unscheduled return visit, return of spontaneous circulation rate in out-of-hospital cardiac arrest patients, in-hospital cardiac arrest incidence, referral rate, and computed tomography (CT) scan utilization.

Results: A total of 37,013 ED visits were included. When compared to the non-EM-trained physicians, patients managed by the seven EM-trained physicians had shorter waiting time (6.1 min vs. 9.2 min, p < 0.001), shorter ED stay (146.5 min vs. 176.1 min, p < 0.001), lower rate of failing to visit patients within the required time (0.8% vs. 1.1%, p = 0.010), lower unscheduled return visit rate (4.9% vs. 5.4%, p = 0.043), and lower CT scan utilization (0.16 [times/patient/visit] vs. 0.18 [times/patient/visit], p < 0.001).

Conclusion: The EM-trained and non-EM-trained physicians' performance at a regional hospital ED differed. Our findings could be used as a reference for healthcare policy-makers and hospital management.

Background: The observational study examines the evolution of emergency medicine residency programs in Taiwan, comparing key program attributes between 2003 and 2021. To identify significant changes in emergency medicine resident program structure, educational resources, and operational aspects.

Methods: According to the previous study carried out in 2003, we conducted a comprehensive analysis of 22 specified items across four domains: contact information, training content, faculty and research, and patient care and benefits, comparing key program attributes between 2003 and 2021. Chi-Square test used for the categorical variables statistical analysis.

Results: The proportion of programs detailing faculty descriptions increased markedly from 63% in 2003 to 95% in 2021, while the mention of residency director roles rose from 4% to 32% in the same period. Conversely, the detailed enumeration of faculty numbers and elective course features saw a decline. Furthermore, the study identified stable areas, such as benefits other than salary and patient numbers, suggesting established standards or external limitations.

Conclusions: The substantial improvements in program structure and educational resources highlight ongoing efforts to enhance training quality and adapt to the changing healthcare landscape. This study contributes valuable insights into the progression of emergency medicine residency.

Hyperkalemia is an acute life-threatening metabolic imbalance that is commonly seen in emergency departments. The primary cause is renal disease, but it also results from increased potassium intake in the diet, severe volume contraction, some medications, and other metabolic disturbances. Signs and symptoms suggestive of hyperkalemia must be recognized early so that life-saving interventions can be initiated. Rapid acquisition of an electrocardiogram (ECG) is important for making an early diagnosis because it can provide clues to the diagnosis long before laboratory results become available. Acute care providers are trained in the progression of alterations on the ECG tracings that occur as serum potassium levels rise. The earliest signs of mild hyperkalemia (5.5-6.5 mmol/L) are tall, narrow-based T waves, best seen in the precordial leads. As the potassium level becomes moderately elevated (6.5-8.0 mmol/L), the PR and QRS intervals become progressively longer, and the P waves might be lost. Severe hyperkalemia (> 8.0 mmol/L) often produces fascicular and intraventricular blocks and an eventual "sine wave" appearance which leads to ventricular fibrillation or asystole if immediate treatment is not provided. Hyperkalemia also often produces bradycardic rhythms along the progression of ECG findings, but this manifestation is not well-known or commonly taught. As a result, life-threatening hyperkalemia may be easily missed until laboratory results reveal the diagnosis. Additionally, standard treatments for bradydysrhythmias, such as atropine and electrical pacing, are often ineffective in treating this life-threatening cause of bradycardia. With early recognition of bradyarrhythmia caused by hyperkalemia, however, the proper treatment can be expedited and clinical decline can be averted.

Helicopter emergency medical services (HEMS) in Japan, known as "Doctor Heli," have revolutionized emergency medical care since their inception in 2001. This paper provides a comprehensive overview of the system's evolution, current operations, and future prospects. Japan's HEMS program, born from lessons learned during the Great Hanshin-Awaji Earthquake in 1995, has grown to 57 units across 46 prefectures, handling approximately 30,000 dispatches annually. The system's primary goal is early medical intervention, significantly improving patient outcomes with a 27% decrease in mortality rate and a 47% reduction in severe aftereffects compared to ground ambulance transport. Despite its success, the system faces challenges such as lack of nationwide standardization and shortage of specialized personnel. To address these issues, advanced technologies like the Medical Trainer simulation system and internet protocol-based mobile radio are being introduced. These innovations aim to enhance training, improve communication, and standardize operations across regions. Furthermore, Japan's HEMS system is expanding its influence internationally, collaborating with countries in Asia and Europe to share knowledge and best practices. As Japan continues to refine its HEMS program, integrating technological advancements and strengthening international cooperation, it not only enhances the quality of domestic emergency medical care but also contributes to the global advancement of pre-hospital care systems.

Penetrating injuries to the heart often lead to pericardial effusion (PCE) that may result in cardiac tamponade which can be rapidly fatal. Thus, early detection of PCE is extremely important in initial resuscitation. A 37-year-old man without any past medical illness was sent to our emergency department by ambulance due to left chest wall penetrating injury by nail gun 30 minutes ago. Upon presentation, the patient was agitated and diaphoretic. The penetration site was in the region of cardiac box, which raised awareness that possible heart injury has been inflicted. Point-of-care ultrasound (POCUS) was used immediately to screen for PCE which was present. In addition, POCUS revealed a hyper-echoic point in the left ventricle (LV) which we speculate is the foreign body (FB). Non-contrast computed tomography confirmed the presence of PCE and FB in the LV. The patient received emergent blood transfusion and was immediately transferred to a level-1 trauma center where removal of FB and cardiorrhaphy of LV apex was performed. He was discharged one week later under stable condition. Take home Message: The presence of hemopericardium in penetrating thoracic trauma may cause life threatening injuries such as cardiac tamponade which warrants immediate intervention. POCUS is a reliable, repeatable, and readily available tool at bedside for detecting PCE in penetrating thoracic trauma patients. Given its high sensitivity and specificity, POCUS should be used as the initial screening tool for the presence of PCE in all thoracic penetrating trauma patients.

The mechanism of exercise-associated collapse (EAC) is multifactorial. Other diagnoses or serious causes of collapse must be excluded immediately. We report a 45-year-old male runner who collapsed during a half-marathon (21 km). The initial assessment showed he had hyperthermia, tachycardia, and hypotension. In the medical tent, we applied non-invasive hemodynamic monitoring, and the results showed his cardiac index was 3.9 L/min/m ² , total peripheral resistance index (TPRI) was 1,199 dynes × sec/cm ⁵ /m ² (normal range: 1,970-2,390 dynes × sec/cm ⁵ /m ² ), stroke volume variance was 8%. The runner had decreased vascular resistance, likely due to heat-related vasodilation, whereas adequate stroke volume variation indicated a relatively sufficient intravascular fluid status. This suggests the runner experienced exertional heat illness rather than a simple EAC. Initially, vigorous intravenous fluid resuscitation was given within the first 30 minutes. After the hemodynamic data indicated a relatively adequate fluid status, the rate of fluid administration was gradually reduced. External cooling methods were implemented which involving ice packing over the neck, axillae, and groin areas. His body temperature decreased. Tachycardia and hypotension were resolved. One hour later, the sequential hemodynamic monitoring showed an increasing TPRI (1,264 dynes × sec/cm ⁵ /m ² ). In our case, the runner displayed peripheral vasodilation. The goal of treatment EAC is to restore adequate tissue perfusion through fluid resuscitation and restoration of vascular tone. Non-invasive hemodynamic serves as a valuable guide for a comprehensive treatment plan for collapsed runners in the field.

Gallbladder hemorrhage is a rare medical emergency, often seen in patients with liver or kidney disease, or cancer. Failure to diagnose and treat it early can lead to shock and death. In this article, we present the case of a 64-year-old woman who presented to the emergency room with unstable vital signs and low blood pressure. Physical assessment found epigastric pain and nausea, but no systemic disease. Ultrasound diagnosed a suspected gallbladder hemorrhage, and she underwent immediate resuscitation and emergency computed tomography (CT). She was consulted with general surgery for gallbladder removal and discharged five days later. Interestingly, six months later, she experienced back pain and discomfort. MRI revealed a suspected bone metastasis, and she was eventually diagnosed with stage IVB lung cancer (T4N3M1c).

Necrotizing fasciitis (NF) is an infection of the deep soft tissues that results in progressive destruction of the muscle fascia and overlying subcutaneous fat. These infections can be sudden, vicious, and fast-spreading. If not treated quickly with antibiotics and debridement of the infected tissue, the patient may develop septic shock, which may lead to multiple organ failure and death. NF is difficult to early diagnose due to the overlying tissue can appear unaffected initially. We report an unusual case of NF of the buttock and left thigh that clinically mimics lumbar disc herniation. This patient was successfully treated with emergent fasciotomy and intensive care. We recommend that patients with low back pain and unilateral leg pain should be diagnosed carefully especially keeping NF in differential diagnosis.

Background: Acute exacerbation of chronic obstructive pulmonary disease (COPD) constitutes an important part of emergency department (ED) admissions. Therefore, risk scores for evaluating prognosis in COPD patients are valuable. The study aimed to determine the prognostic accuracy of Dyspnea, Eosinopenia, Consolidation, Acidemia, and Atrial Fibrillation (DECAF) and Ottawa COPD Risk Scale in predicting short-term outcomes in patients presenting to the ED with COPD exacerbation.

Methods: This was a prospective cohort study conducted in a tertiary care hospital. All adult patients who presented to the ED with COPD exacerbation between June 2021 and June 2022 were included. DECAF and Ottawa COPD risk scores were calculated for each patient at ED admission. The primary outcome was all-cause mortality within 30 days of discharge.

Results: The data of 137 patients were analyzed. At the end of the 30-day period, 16 (11.7%) patients died, and 11 (8.0%) were admitted to the ICU. Based on receiver operating characteristic (ROC) curves plotted for mortality, the area under the curve (AUC) for the DECAF score was 0.762 (95% confidence interval [CI]: 0.649-0.876, p = 0.001), while the AUC for the Ottawa score was 0.796 (95% CI: 0.704-0.888, p < 0.001). The scores did not differ for mortality estimation ( p = 0.626). Using a score cut-off value of 3 for both scores for mortality outcome, the sensitivity/specificity values were 63%/78% for DECAF and 100%/34% for Ottawa.

Conclusion: Both risk scores are useful tools for predicting short-term outcomes in patients presenting to the ED after COPD exacerbation and can be used for risk management in the ED.