Open Access Emergency Medicine最新文献

Introduction: Mechanical ventilation is the primary method of supporting organ function for patients admitted to intensive care units (ICU). The information on the characteristics and outcomes of patients requiring mechanical ventilation is essential to understanding the causes of mortality among mechanically ventilated patients. However, the available literature in developing countries, including Ethiopia, is limited.

Objective: The objective of this study was to assess the characteristics and outcomes of mechanically ventilated patients in adult intensive care units in selected public hospitals, in Addis Ababa, Ethiopia, from 2019 to 2020.

Methods: An institutional-based cross-sectional study design was employed. All adult patients who were mechanically ventilated and admitted to ICU for at least 24 hours between July 2019 and July 2020 were included in the study. The collected data were evaluated with SPSS version 26 software. Multiple logistic regression models were used to indicate the association between dependent and independent variables. The variables, which have an independent association with poor outcomes, were identified with a p-value less than 0.05.

Results: Of 180 mechanically ventilated patients, 98(54.4%) were male. The main reason for ventilation was respiratory failure. The mean duration of stay on the ventilator was 7.09± 6.06, and the mortality rate in mechanically ventilated patients was 41.7%. The mortality rate was higher in patients with cardiac diseases 43(57.70%). Inotropic use, not taking sedation, and length of stay on a mechanical ventilator were independently associated with mortality.

Conclusion: The mortality rate of mechanically ventilated patients in the selected public hospitals was high. The clinicians must strive to balance the necessity and benefit of sedation use with the potential to negatively affect the patient outcome. In addition, the risk:benefit assessment of ventilation must be done for all patients requiring ventilator support.

Objective: To compare the effectiveness of applying the back plate marking method vs the standard method, to a mechanical chest compression device, in regards to reducing the duration of chest compression interruptions during a simulated cardiac arrest.

Methods: An experimental study, one group pretest posttest design, conducted in a university-based hospital from November 2020 to October 2021. The study recruited 20 participants including emergency medical residents and paramedics. The participants were randomized into three-person teams and applied the device in both standard and back plate marking methods in sequential order. Teams were required to use a mechanical chest compression device in a manikin-based OHCA simulation to assess performance.

Results: The median time pause for the deployment of the upper part of the device was significantly reduced (16 vs 21s, P < 0.01) in the back plate marking method, as was the total pause for device deployment (31.5 vs 38.75s, P = 0.03) and the proportion of total hands-off time attributable to device application interruption (43.08% vs 49.18%, P = 0.02). There was no difference between groups in the duration of all compression interruptions (70.5 vs 82.75s, P = 0.20) and compression fractions (77.85 vs 76.91%, P = 0.19).

Conclusion: The back plate marking method was a significantly reduced time of the deployment of the upper part of the device and in regards to the overall pause for device deployment, but there was no difference in CPR quality between the two methods.

Purpose: Acute aortic dissection (AAD) is a highly fatal disorder if not promptly diagnosed. Some international studies have suggested that serum d-dimer levels may be used to exclude AAD, but data are limited. We sought to confirm that d-dimer levels are elevated in American patients with AAD. Additionally, we sought to estimate the test characteristics of the d-dimer for AAD.

Patients and methods: We performed a retrospective analysis of patients in the Hospital Corporation of America database who arrived at the hospital between 2015 and 2019. We queried the database to find patients who had a diagnosis of AAD or (nonspecific) chest pain, and who also had a d-dimer performed within 24 hours of arrival at the hospital. The median d-dimer was compared in those diagnosed with AAD versus chest pain. We estimated the test characteristics of d-dimer for AAD at the standard cutoff value of 500 ng/mL.

Results: In total, 48,902 patients met the criteria for analysis, including 572 with AAD and 48,330 with chest pain. The median d-dimers were 2455 ng/mL and 385 ng/mL for the AAD and chest pain groups, respectively (p < 0.0001). Using a cutoff of 500 ng/mL, the sensitivity of the d-dimer was 91.1% and the specificity was 71.4%.

Conclusion: Serum d-dimer values are higher in patients with AAD than in those with nonspecific chest pain. At the standard cutoff of 500 ng/mL, the serum d-dimer has a high sensitivity for AAD, but not high enough that d-dimer levels alone can be used in isolation to exclude AAD.

Purpose: Pediatric sepsis guidelines recommend rapid intravenous fluid (IVF) bolus administration rates (BAR). Recent sepsis studies suggest that rapid BAR may be associated with increased morbidity. We aimed to describe the association between emergency department (ED) IVF BAR and clinical outcomes in pediatric sepsis.

Patients and methods: Secondary post-hoc analysis of retrospective cohort data from 19 hospitals in the Pediatric Septic Shock Collaborative (PSSC) database. Patients with presumed septic shock were defined by severe sepsis/septic shock diagnostic codes, receipt of septic shock therapies, or floor-to-ICU transfers within 12 hours from ED admission for septic shock. Patients (2 months-21 years) with complete data on weight, antibiotic receipt, bolus timing, and bolus volumes were included. The primary outcome was 30-day mortality. Associations between BAR and mortality and secondary (intubation or non-invasive positive pressure ventilation = NIPPV) outcomes were assessed using unadjusted and adjusted logistic regression.

Results: The PSSC database included 6731 patients; 3969 met inclusion and received a median ED volume of 40.2 mL/kg. Seventy-six (1.9%) patients died, 151 (3.8%) were intubated, and 235 (5.9%) had NIPPV administered. The median BAR was 25.7 mL/kg/hr. For each 20 mL/kg/hr increase in BAR, the adjusted odds ratio (aOR) for 30-day mortality [aOR = 1.11 (95% CI 1.01, 1.23)], intubation [aOR = 1.25 (95% CI 1.09, 1.44)], and NIPPV [aOR = 1.20 (95% CI 1.05, 1.38)] significantly increased.

Conclusion: Faster ED IVF bolus administration rates in this pediatric sepsis database were associated with higher adjusted odds of death, intubation and NIPPV. Controlled trials are needed to determine if these associations are replicable.

Background: In Thailand, most primary care hospitals cannot measure serum lipase and amylase; no 24 hours computed tomography and magnetic resonance imaging available, and no on-call gastroenterologists. Thus, acute pancreatitis cannot be diagnosed based on the established diagnostic criteria that require this information. The resultant delayed management increases morbidity and mortality. This study was performed to create a clinical prediction score for early diagnosis of acute pancreatitis in emergency departments without requiring a computed tomography scan or laboratory measurement to assist in the initial diagnosis, treatment, or referral.

Methods: Patients with suspected acute pancreatitis who had available data regarding lipase and amylase measurements and visited the emergency department from June 2019 to August 2020 were retrospectively analyzed. The baseline predictive factors were compared between patients with and without acute pancreatitis according to the 2012 revised Atlanta classification. Multivariable logistic regression was used to explore potential predictive factors and develop a clinical prediction score for the diagnosis of acute pancreatitis.

Results: A total of 506 eligible patients, 84 (16%) had acute pancreatitis. The PRE-PAN score [area under the receiver operating characteristics curve, 0.88; 95% confidence interval (CI), 0.84-0.93] included six factors: alcohol drinking, epigastric pain, pain radiating to the back, persistent pain, nausea or vomiting, and the pain score. A score of >7.5 points suggested a high probability of acute pancreatitis [positive likelihood ratio, 6.80 (95% CI, 4.75-9.34; p < 0.001); sensitivity, 66.7% (95% CI, 54.6-77.3); specificity, 90.2% (95% CI, 86.6-93.1); positive predictive value, 58.5% (95% CI, 47.1-69.3);, 92.9% (95% CI, 89.6-95.4)].

Conclusion: A PRE-PAN risk score is a screening tool for predicting acute pancreatitis without using the lipase concentration or radiological findings. A high predictive score, especially >7.5, suggests a high probability of acute pancreatitis.

Background: Studies showed that each year people lose their life on the road and many people are disabled. The majority of this disability was caused by orthopedic injury related to road traffic accidents. However, in the context of Ethiopia, studies ascribed to orthopedic injuries related to road traffic accidents are limited. The study aimed to assess the pattern of orthopedic injuries related to road traffic accidents among patients managed at the emergency department of Black Lion Hospital.

Methods: An institutional-based cross-sectional study was conducted on 354 victims of road traffic accidents with orthopedic injuries who were visiting the Emergency department of Black Lion Hospital. Patient charts were selected by systematic random sampling technique and the data was entered into Epi-data version 4.4.2.2 and exported to the static package for social science window version 26, and descriptive statistics were used for analysis.

Results: The study reveals that males were mostly injured persons (71.7%) with the age group of 13-24 were the most injured. Passenger car accounts 36.3% of causes of injury followed by motorbikes (27.4%) and lower limbs were the most common anatomic site of injuries (47.9). Of all injury types, a fracture is the most common one with 71.1%, especially lower limb fracture (42.1%). More than half victims (59.5%) had open wounds, and almost half of the study subjects (51.8%) experience Road traffic accidents while they are crossing or walking along the way.

Conclusion: Orthopedic injuries related to road traffic accidents are the main cause of death and disability in many individuals, especially in reproductive age groups. Therefore, policy-makers should be aware of different patterns of orthopedic injuries associated with a victim of road traffic accidents to have an appropriate and sustainable capacity to manage the orthopedic injuries.

Abdominal pain is a common presenting complaint in the emergency department, and utilization of diagnostic imaging is often a key tool in determining its etiology. Plain radiography has limited utility in this population. Computed tomography (CT) is the imaging modality of choice for undifferentiated abdominal pain. Ultrasound and magnetic resonance imaging may be helpful in specific scenarios, primarily in pediatrics and pregnancy, and offer the benefit of eliminating ionizing radiation risk of CT. Guidance for imaging selection is determined by location of pain, special patient considerations, and specific suspected etiologies. Expert guidance is offered by the American College of Radiology Appropriateness Criteria^® which outlines imaging options based on location of pain.

Nitroglycerin, a fast-acting vasodilator, is commonly used as a first-line agent for angina in the emergency department and to manage chest pain due to acute coronary syndromes. It is also a treatment option for other disease states such as acute heart failure, pulmonary edema, and aortic dissection. Nitroglycerin is converted to nitric oxide, a potent vasodilator, in the body, leading to venodilation at lower dosages and arteriodilation at higher dosages that results in both preload and afterload reduction, respectively. Although nitroglycerin has historically been administered as a sublingual tablet and/or spray, it is often given intravenously in the emergency department as this enables titration to effect with predictable pharmacokinetics. In this review article, we outline the indications, mechanism of action, contraindications, and adverse effects of nitroglycerin as well as review relevant literature and make general recommendations regarding the use of nitroglycerin in the emergency department.

Background: Richter's type recurrent indirect inguinal hernia remains to be an extremely rare entity reported scarcely. It may present with grave complications in the absence of symptoms and signs of intestinal obstruction. The aim of this study is to report a rare case of Richter's hernia after a previously repaired indirect inguinal hernia.

Case presentation: A 31-year-old male farmer came up with complaints of colicky abdominal pain and two episodes of vomiting. He had a previous right inguinal surgery. A physical examination revealed a full abdomen with right inguinal tenderness and oblique surgical scar. Abdominal ultrasound showed a bowel segment entrapped in the deep inguinal ring of the inguinal canal. Right inguinal exploration was done, and the finding was a gangrenous Richter's type recurrent indirect inguinal hernia. The patient was discharged and improved on the seventh post-operative day after resection and anastomosis.

Discussion: Richter's hernia is a rare form of hernia that occurs when the anti-mesenteric border of the bowel is partly trapped in a tight hernial ring. Its rarity, combined with the fact that it may present in the absence of typical symptoms and signs of intestinal obstruction and local physical findings, poses a diagnostic challenge which often end up with complications like gangrenous bowel at the time of diagnosis.

Conclusion: Richter's hernia can occur in an extremely rare form as Richter's type recurrent indirect inguinal hernia. A high degree of suspicion, an early referral and timely imaging on the provider's side may prevent mortality and morbidity.

Objective: Difficult laryngoscopy is associated with difficult intubation, an increasing number of endotracheal intubation attempts, and adverse events. Clinical prediction of difficult airways in an emergency setting was limited in sensitivity and specificity. This study developed a new model for predicting difficult laryngoscopy in the emergency department.

Methods: This retrospective cohort study was conducted using an exploratory model at the Emergency Medicine of Ramathibodi Hospital. The study was conducted from June 2018 to July 2020. The eligibility criteria were an age of ≥15 years who undergo intubation in the emergency department. Difficult laryngoscopy was defined as a Cormack-Lehane grade 3 and above. The predictive model and score were developed by multivariable logistic regression analysis.

Results: A total of 617 patients met the eligibility criteria; 83 (13.45%) had difficult laryngoscopy. Five independent factors were predictive of difficult laryngoscopy. Significant factors were M: limited mouth opening, O: presence of obstructed airway, N: poor neck mobility, T: large tongue, and H: short hypo-mental distance. The difficult laryngoscopy score had an accuracy of 89%. A score of >4 increased the likelihood ratio of difficult laryngoscopy by 7.62 times.

Conclusion: The MONTH Difficult Laryngoscopy Score of >4 was associated with difficult laryngoscopy.