Journal of Emergency Medicine最新文献

Background

Individuals with chronic obstructive pulmonary disease (COPD) constitute a significant portion of patients who present to the emergency department with dyspnea. However, there is no ideal method for predicting mortality or making hospitalization decisions in the emergency department (ED). In this regard, objective findings are needed for these patients. Since there are no objective findings regarding the hospitalization decision, there may be an increase in the re-admission rate of patients who needed hospitalization but were decided to be discharged. Side-stream end-tidal carbon dioxide (EtCO₂) measurements offer a non-invasive, easy-to-interpret, quickly accessible, and reproducible method that can be applied at the bedside.

Objectives

The aim of this study was to evaluate the relationship between the alpha angle values obtained by capnography and readmission rates within 30 days for patients experiencing COPD exacerbations who presented to the ED with dyspnea and were discharged after treatment.

Methods

In this study, we studied with 130 participants presented to the emergency department of a tertiary care university hospital with dyspnea, who are >18 y. Forty patients were excluded after evaluation for eligibility for the study. Thus, the data of 90 patients included were analyzed. We obtained alpha angle and EtCO₂ values for all patients at the time of admission and also after treatment. The primary outcome measure of the study was the relationship between the patients’ readmission situations within 30 days of the alpha angle measurements. The secondary outcome measure was the association between patients’ EtCO₂ values ​​and readmission within 30 days.

Results

It was observed that both the pretreatment alpha angle values and the posttreatment alpha angle variables were statistically significant in predicting the readmission of the patients within 30 days (p = 0.001, p = 0.003)

Conclusion

The results of this study show that alpha angle values measured for patients with COPD who present to the ED with the complaint of dyspnea may be used to predict readmission.

Background

Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope.

Case Report

A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli.

Why Should an Emergency Physician Be Aware of This?

Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Background

Abdominal compartment syndrome (ACS) is typically attributed to critically unwell patients with trauma, burns, post surgery, and massive ascites. A rare but fatal cause of ACS is bulimia nervosa (BN), which is an eating disorder characterized by bingeing, followed by methods to avoid weight gain, including purging.

Case Report

We present a case of a 20-year-old woman who presented with abdominal pain and distension after consuming a large quantity of food the previous night and was unable to purge. She was initially managed conservatively and discharged home, but returned subsequently on the same day with clinical features of ACS secondary to acute gastric distension. Decompression resulted in life-threatening reperfusion injury with critical electrolyte abnormalities and fatal cardiac arrest in the operating theatre.

Why Should an Emergency Physician Be Aware of This?

A systematic review of the literature found only 11 case reports of ACS secondary to BN, of which only 6 patients survived due to early diagnosis and decompression. Inability to purge and lower limb ischemia appeared to be associated with increased mortality. As BN is a common emergency presentation, the case and systematic review highlights the need to consider ACS as a potentially life-threatening complication of binge eating, particularly when there is unsuccessful purging.

Background

Stethoscopes, well established as vectors, are recommended to be cleaned by alcohol swab scrubbing for 60 seconds. The new 2024 CDC guidelines mandate stethoscope cleaning between every patient. Unfortunately, guideline failure is poorly described, especially in immunocompromised cancer patients. We thus performed a model examining the expense of stethoscope hygiene using the probabilities and costs of stethoscope infection transmission from 2 well described pathogens; Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridioides difficile infection (CDI), in both immunocompromised and immunocompetent patients.

Methods

We performed an economic analysis of pathogen transmission costs and consequences in immunocompromised and immunocompetent ED patients. Variables were defined as auscultations/day in a medium sized ED =90 (30/physician, 3 physicians/24 hours), stethoscope cleaning time =60 seconds, annual ED physician salary =$352,000.00, published stethoscope contamination rates of MRSA and CDI =7.4% and 5%, respectively, and published hospital acquired infection costs for MRSA and CDI =$38,561.00 and $24,205, respectively. The immunocompromised rate was defined as 2.7%, and the estimated probability of infection occurring after exposure in immunocompetent and immunocompromised patients is analyzed by ranges of 1-3% and 10-30%, respectively.

Results

Using the above definitions provides an estimation of 32,850 auscultations/year/ED, which equates to 547 annual hours of emergency physician stethoscope cleaning; prorated by salary, results in an annual ED cost of $115,940.00/yr.

Conclusions

Cleaning personal stethoscope costs $115,940.00/yr, but its failure may cost up to $4.98 million/yr/hospital.

Background

The need for a stronger evidence-base in paramedicine has precipitated a rapid development of prehospital research agendas. Paramedics are increasingly involved in research, leading to changes in their role. Yet, the integration of research responsibilities has proven to be challenging, resulting in varying attitudes and levels of engagement.

Objective

This systematic review aimed to explore paramedics’ views and experiences of research as researchers during training and within practice.

Methods

A systematic search was performed across six databases. Qualitative empirical peer-reviewed articles that discussed paramedic perspectives on engaging with research activity were included. Of 10,594 articles identified initially, 11 were included in the final synthesis after quality appraisal. Data were extracted and subjected to narrative synthesis.

Results

The following four themes were identified: motivation to engage, moral dilemmas, structural issues within the profession, and reflections on trial involvement. Attitudes toward research, understanding of related concepts, and the drive for patient benefit were interwoven core issues.

Conclusions

Research was highly valued when links to patient benefit were obvious, however, this review highlights some cultural resistance to research, particularly regarding informed consent and changes to standard practice. Paramedic research methods training should provide structured opportunities to explore concerns and emphasize the role of research in developing a high-quality evidence base to underpin safe practice. Currently, there is inadequate organizational support for paramedics to engage effectively in research activity, with minimal allocations of time, training, and remuneration. Without properly integrating research activity into the paramedic role, their capacity to engage with research activity is limited.

A 49-year-old male with history of intravenous drug use presented to the Emergency Department with localized right arm swelling that has been slowly growing for months. On physical exam, there was a golf ball sized mass in the right antecubital fossa without overlying skin changes and no neurovascular deficits in the distal extremity. Point-of-care ultrasound (POCUS) was performed utilizing a water bath with visualization of bidirectional swirling in a round cavity adjacent to the brachial artery. Aneurysms are abnormal focal dilations that result from vascular wall defects. Ultrasound has been reported to have 94% sensitivity and 97% specificity for diagnosis of pseudoaneurysms. On color doppler ultrasound, pseudoaneurysm is characterized by the pathognomonic “yin-yang” sign. In the case of the 49-year-old male with a right antecubital mass and history of IVDU, the proposed mechanism of injury was trauma to the arterial wall secondary to auto-injection. POCUS has been found to improve identification of abscesses and its incorporation in patient evaluation can guide clinical management, prevent unwanted iatrogenic exsanguination, and determine whether there is a need for urgent vascular surgery intervention, particularly in high-risk patients.

Background

Oncology patients presenting to EDs with acute respiratory illnesses (ARI) require a broad workup and early treatment due to risk of underlying infection and immunocompromised status. Early antibiotic administration is often required as determining a nonbacterial source is time consuming. A novel host bio-array developed to rapidly differentiate bacterial from viral sources could improve ED resource utilization, reduce unnecessary antibiotics, and increase healthcare quality.

Methods

An IRB approved subject on multiple immunosuppressants presents with ARI and positive SIRS criteria. The MeMed BV® (BV) is an FDA approved rapid immunoassay that reports a computationally integrated score (0-100) of three host proteins (TNF-related apoptosis-inducing ligand (TRAIL), interferon gamma-induced protein 10 (IP-10), and C-reactive protein (CRP). The BV score and ED standard of care tests were obtained in a modified ED sepsis protocol (mEDSP). Scores above 65 are associated with bacterial infections, while scores below 10 are associated with viral infections. Cost of laboratory, radiology, professional and facilities fees (room charges, nursing, and ancillaries) were summed for the admission. Investigators received three surveys to: (1) establish pretest probability of disease, (2) determine posttest probability after receiving BV results, (3) query what resources might be withheld or changed if presented with the BV test results early.

Results

The BV reported a ‘0’ value (viral source) within 20 minutes. Further testing confirmed no bacterial source of infection. An adjudicated cost and resource review of the mEDSP and admission revealed a potential reduction of unnecessary antibiotics by 59%, lab testing by 24.2%, and overall costs by 23.2%. Admission time could have been reduced by 24 hours (43%). Furthermore, the ED physician was amenable to changing care based on this test.

Conclusion

Significant improvement in resource utilization and greater quality was identified with early identification of nonbacterial sources in ARI in the ED. Adjunct biomarkers differentiating viral from other sources can improve quality and resource utilization when deployed early in the ED. Further trials in the Emergency Oncology realm are necessary.

Background

In recent years, a dramatic breakthrough in cancer treatment has arisen with the advent of immune-checkpoint inhibitor (ICI) therapy. However, these therapies are accompanied by multiple unique immune-related adverse effects that can present as an oncologic emergency to emergency department (ED). Here we describe the characteristics of cancer patients with no previous diagnosis of adrenal insufficiency who present to the emergency with low adrenocorticotropic hormone and cortisol levels following ICI therapy.

Methods

Using data from a comprehensive cancer center, we conducted a retrospective cohort study of patients 18 years and older who received ICI between April 1 st, 2018, and December 31st, 2022, and presented to the ED with low ACTH and total cortisol levels. The billing database was used to exclude patients with prior diagnosis of adrenal insufficiency based on the ICD-10 codes. Demographics, clinical and cancerrelated data were collected from the institution's data warehouse. Descriptive statistics were used to analyze the data.

Results

A total of 101 cancer patients were identified based on the eligibility criteria, with a median age of 63 years (interquartile range= 58-72 years), who were mostly White race (83.2 %) and Not Hispanic or Latino ethnic group (86.1%). Melanoma, lung, renal and head and neck cancer were the most common cancer types for these patients. The median Charlson comorbidity index was 8 (interquartile range: 7–9). Most (98%) of the patients presented as level 2 or 3 on the emergency severity index. Almost all patients (94%) were admitted, of these, 26 patients (25.7%) were placed in the observation unit. Of the patients who got admitted, around 10% were placed in the intensive care unit during their hospital stay.

Conclusion

The clinical use of ICI is continually broadening and certain ICI-induced toxicities including endocrinopathies requires immediate medical attention. We found that most patients presenting to the ED with low ACTH and cortisol levels with no previous diagnosis of adrenal insufficiency after ICI therapy require admission and close monitoring. Further studies are needed to better evaluate the incidence and outcomes of ICI-induced adrenal insufficiency among cancer patients after ICI therapy.

Background

Syphilis is long regarded as the “great mimicker” for its variety of symptoms and clinical manifestations. Rarely, it can present with renal involvement, particularly nephrotic syndrome. This is an uncommon initial presentation, particularly in pediatrics.

Case Report

We present the case of a 17-year-old male adolescent who presented to the emergency department with a chief symptom of abdominal pain. In addition, he was found to have a number of stigmata characteristic of both syphilis and nephrotic syndrome, including a rash and diffuse edema, particularly in the lower extremities. This led to the diagnosis of nephrotic syndrome secondary to syphilis infection. Prompt diagnosis and treatment of syphilis resulted in resolution of both kidney injury and symptoms of the underlying infection.

Why Should an Emergency Physician Be Aware of This?

This case highlights the variety of manifestations of sexually transmitted infections, particularly in the pediatric population. It demonstrates how identifying syphilis as the inciting event led to the correct treatment management for the patient. This presentation serves to teach and remind emergency physicians of the wide-ranging presentations for sexually transmitted infections, particularly syphilis, and the necessity of obtaining a sexual history even in adolescent patients.