Journal of acute medicine最新文献

Sepsis is a potentially fatal organ failure produced by the host's immune response to infection. It is critical to identify risk factors associated with a poor prognosis in septic patients in order to develop new therapy options. Vitamin D deficiency (25-hydroxyvitamin cholecalciferol < 20 ng/mL) is common in critical and septic patients. Serum vitamin D concentrations are associated with an increased incidence of mortality in critically ill adult patients. In critically ill patients, vitamin D supplementation (a very high vitamin D ₃ or cholecalciferol loading dosage as a single bolus dose ranging from 400,000 to 540,000 IU) is feasible and safe. Some of the trials and their post-hoc analyses evaluating vitamin D supplementation in severely sick individuals, including septic patients, suggested possible benefits in mortality (reduced 28-day mortality in the range of 8.1%-17.5%), and other outcomes (reduction in hospital length in the range from 9 to 18 days, and decrease in duration of mechanical ventilation in the range from 5 to 10 days). Despite the fact that many studies support the provision of vitamin D to septic patients, there are still many studies that contradict this opinion, and there is still debate about the recommendation to use vitamin D in sepsis. A pragmatic clinical approach in severe sepsis could be supplementation of vitamin D if serum levels are diminished (< 30 ng/mL). It appears that a single ultrahigh dose of vitamin D ₃ (cholecalciferol) could be administered to the septic patient via an enteral tube, followed by daily or monthly maintenance doses. Parenteral administration might be reserved for a subgroup of septic patients with gastrointestinal, hepatic, or renal dysfunction. Future clinical trials designed exclusively for septic patients are required to assess the potential advantages of vitamin D. Possible impacts of selective activators of vitamin D receptors, such as paricalcitol, should be elucidated in sepsis. This emphasizes the requirement for more study and confirmation of any potential beneficial effects of vitamin D in sepsis.

The rapid progression of artificial intelligence (AI) in healthcare has greatly influenced emergency medicine, particularly in Taiwan-a nation celebrated for its technological innovation and advanced public healthcare. This narrative review examines the current status of AI applications in Taiwan's emergency medicine and highlights notable achievements and potential areas for growth. AI has wide capabilities encompass a broad range, including disease prediction, diagnostic imaging interpretation, and workflow enhancement. While the integration of AI presents promising advancements, it is not devoid of challenges. Concerns about the interpretability of AI models, the importance of dataset accuracy, the necessity for external validation, and ethical quandaries emphasize the need for a balanced approach. Regulatory oversight also plays a crucial role in ensuring the safe and effective deployment of AI tools in clinical settings. As its footprint continues to expand in medical education and other areas, addressing these challenges is imperative to harness the full potential of AI for transforming emergency medicine in Taiwan.

For several decades, hydrogen sulfide (H₂S) has been a toxic gas affecting people, particularly in workplaces. However, no effective therapy is available to counteract H₂S poisoning. Herein, we report the case of a 34-year-old male field worker who experienced H₂S poisoning due to an accident at work. He presented to the emergency room with dyspnea, drowsiness, and dizziness. Computed tomography revealed a normal brain mass. An initial electrocardiogram revealed sinus tachycardia. Therefore, 10 mL nitrite was administered intravenously. However, the symptoms were not relieved as expected. Hyperbaric oxygen was promptly administered. Symptoms were relieved rapidly after three sessions of hyperbaric oxygen therapy. Subsequently, the patient completely recovered. During severe H₂S intoxication, early administration of hyperbaric oxygen therapy can prevent the disruption of aerobic cellular respiration and save lives.

Background: We aim to assess the differences in ventilator mechanics and mortality of acute respiratory distress syndrome (ARDS) between patients with and without COVID-19. It might serve as a milestone in reshaping management protocols by providing very preliminary evidence in this direction.

Methods: It was a cross-sectional study that included adult patients aged 18 years or above admitted to the medical intensive care unit of our tertiary care hospital from January to December 2021 with the diagnosis of ARDS. Patients were divided into two groups. Group I were patients who had ARDS with COVID-19 infection while group II were those who had ARDS without COVID-19 infection. Both groups were compared in terms of clinical and respiratory mechanics of mechanical ventilators and mortality.

Results: The study included 135 patients, 68 of whom were in group I, and 67 were in group II. In the COVID-19 group, the median age was 60; while in the non-COVID-19 group, it was 64. There were 50% male patients in both groups. ARDS was more severe in COVID-19 (n = 44, 58%) than in the non-COVID group (n = 31, 41.3%, p-value = 0.030). The median PaO₂/FiO₂ ratio was 122.5 (interquartile range [IQR]: 93-160) in COVID-19 and was 180 (IQR: 127-248) in the non-COVID-19 group. Patient proning was higher (63% vs. 37%) in the COVID-19 group. In the COVID-19 group, 44 patients died compared to 32 in the non-COVID group (p-value = 0.060).

Conclusions: COVID-19 patients had severe ARDS compared with non-COVID patients. Despite this, ventilator mechanics and mortality were not significantly different between both groups. It appears that more proning strategies were observed in the COVID-19 group and may have some positive effects.

Blunt abdominal injury with pelvic fracture is common in polytrauma cases and is a major challenge for emergency physicians. Fluid resuscitation and massive transfusion protocol should be activated when pelvic fracture patients are found in hypovolemic shock. At the emergency department, resuscitative endovascular balloon occlusion of the aorta may be performed to temporarily control bleeding. Finally, a damage control operation or trans-arterial embolization may be performed in the hybrid operating room.

In the literature no case of gastro-caval fistula due to penetrating trauma has been reported. We aimed to present a case of gastro-caval fistula presenting with massive hematemesis after a penetrating injury. A 20-year-old male patient applied to the emergency department with a complaint of projectile hematemesis after a knife penetrated the epigastric region. Contrast-enhanced abdominal computerized tomography (CT) showed a large hematoma around the inferior vena cava (IVC) and a fistula tract extending between the IVC and the gastric antrum. The patient underwent vena cava ligation and primary gastric repair. The patient, who was hypotensive and intubated in the post-operative intensive care unit, died on the second day after the operation. Because of the risk of sudden hypotension and shock from massive bleeding, gastro-caval fistula should be kept in mind in penetrating trauma; a rapid diagnosis should be made using a contrast-enhanced CT scan.

Background: Elderly patients with intra-abdominal infection are more vulnerable to sepsis progression, especially in those who had concomitant bacteremia. The time to positivity (TTP) of blood cultures in patients with bacteremia is considered to be a prognostic factor for some bacterial species. This study aimed to investigate the prognostic value of TTP in elderly patients with intra-abdominal infection and Klebsiella pneumoniae bacteremia.

Methods: A retrospective observational, case-control study was conducted at a single tertiary referral medical center. All elderly (aged ≥ 65 years) patients diagnosed with intra-abdominal infection and Klebsiella pneumoniae bacteremia in the emergency department between July 1, 2016, and June 30, 2021 were enrolled. The baseline characteristics, TTP of blood cultures, management strategy, and outcomes of each eligible patient were recorded and analyzed. The primary outcome was to examine the association between TTP and the 30-day mortality risk in enrolled patients.

Results: A total of 101 patients were included in the study. The overall 30-day mortality rate was 11.9% (12/101). The median TTP of Klebsiella pneumoniae in the eligible patients was 12.5 (11-16) hours. There was a stepwise significantly decreased mortality rate as TTP increased (p = 0.04). The TTP had a moderate mortality discrimination ability (area under receiver operating characteristic curve = 0.75, 95% CI = 0.65-0.83, p < 0.01). Furthermore, the Pittsburg bacteremia score (hazard ratio [HR] = 2.19, p < 0.01) and TTP (HR = 0.82, p = 0.04) were identified as independent factors associated with 30-day mortality.

Conclusions: TTP was associated with 30-day mortality risk in elderly patients with Klebsiella pneumoniae bacteremia and intra-abdominal infection. Clinicians can utilize TTP for risk stratification, and initiate prompt treatment in those patients with shorter TTP.

Background: Hospitalized coronavirus disease 2019 (COVID-19) patients have higher mortality rates. Parameters to predict mortality are needed. Therefore, we investigated the power of procalcitonin/albumin ratio (PAR) and C-reactive protein/albumin ratio (CAR) to predict in-hospital mortality in hospitalized COVID-19 patients.

Methods: In this study, 855 patients were included. Patients' PAR and CAR values were recorded from the hospital information management system. The patients were evaluated in two groups according to their in-hospital mortality status.

Results: In-hospital mortality was observed in 163 patients (19.1%). The median PAR and CAR values of patients in the non-survivor group were statistically significantly higher than those of patients in the survivor group, PAR (median: 0.07, interquartile range [IQR]: 0.03-0.33 vs. median: 0.02, IQR: 0.01-0.04, respectively; p < 0.001); CAR (median: 27.60, IQR: 12.49-44.91 vs. median: 7.47, IQR: 2.66-18.93, respectively; p < 0.001). The area under the curve (AUC) and odds ratio (OR) values obtained by PAR to predict in-hospital mortality were higher than the values obtained by procalcitonin, CAR, albumin, and CRP (AUCs of PAR, procalcitonin, CAR, albumin, and CRP: 0.804, 0.792, 0.762, 0.755, and 0.748, respectively; OR: PAR > 0.04, procalcitonin > 0.14, CAR > 20.59, albumin < 4.02, and CRP > 63; 8.215, 7.134, 5.842, 6.073, and 5.07, respectively). Patients with concurrent PAR > 0.04 and CAR > 20.59 had an OR of 15.681 compared to patients with concurrent PAR < 0.04 and CAR < 20.59.

Conclusions: In this study, PAR was found to be more valuable for predicting in-hospital COVID-19 mortality than all other parameters. In addition, concurrent high levels of PAR and CAR were found to be more valuable than a high level of PAR or CAR alone.

This review assessed the development of Taiwan's emergency medical services (EMS) and focused on the optimizing initiatives of the EMS systems, the current state of Taiwan's EMS system, EMS benchmarks in different regions of Taiwan, EMS response during the coronavirus disease 2019 (COVID-19) pandemic, and future design. In the past decade, there has been a noticeable increase in prehospital services, numerous optimizing initiatives to improve patient prognosis, and the medical oversight model. Taiwan's current EMS system, including the dispatch system, out-of-hospital cardiac arrest (OHCA) patient management, time-sensitive critical illness in prehospital settings, and disaster response, has undergone significant improvements. These improvements have been demonstrated to have a measurable impact on patient outcomes, as supported by medical literature. Each region in Taiwan has developed a unique EMS system with local characteristics, such as the implementation of the Global Resuscitation Alliance 10 steps for OHCA-related quality control, hearing automated external defibrillator program, a five-level prehospital triage system, an island-hopping strategy for patients with major trauma, dispatcher-assisted teamwork for OHCA resuscitation, and optimized prehospital care for acute coronary syndrome patients. In response to the COVID-19 pandemic from 2019 to 2023, Taiwan's EMS implemented measures to combat the outbreak such as interagency collaboration to obtain patient's personal information, to optimize prehospital management initiatives, and to provide financial compensation and personal insurance for emergency medical technicians. The areas that need focus include integrating prehospital and in-hospital information to build a national-level database (One-Stop Emergency Management), increasing public awareness of first responders and emergency casualty care, and evolving the EMS system by incorporating private EMS system, initiating school-based education of paramedicine, and legally recognizing paramedics as medical and health care personnel. By improving these areas, we can better prepare for the future and ensure that Taiwan's EMS system continues to provide high-quality care to those in need.