Open Access Emergency Medicine最新文献

Background: Numerous dermatological conditions present in the emergency department (ED). Some have subtle presentations, yet most provoke patient suffering. Such conditions need to be identified and managed properly. This study aims to epidemiologically describe the patterns and characteristics of dermatological conditions presenting to a secondary teaching hospital's ED.

Methods: This retrospective chart review study analyses data on dermatological conditions that have presented to the ED between January 2021 and May 2023. The data gathered included sociodemographic variables, date and shift of visit, triage level, dermatological complaint characteristics, management, and discharge status. Comparative analysis was performed, and the level of significance was set at 0.05.

Results: The total number of cases was 301. The median age was 12 years (IQR = 4-30 years), with similar distribution between males and females (50.17% and 49.83% respectively). Most cases had presented to the ED during the morning shift (49.83%). Triage levels IV and V made up 94.69%, and only 5.32% belonged to triage level III. Most presented during the winter season (32.89%). The median visit duration was 312 minutes, and of all cases treated, only 10 required a return visit to the ED. Also, 41.53% were discharged and 58.47% required further management. Maculopapular rashes were the most common finding (35.55%). Bullae/blisters and erythroderma accounted for those that most often required further management. The two most prescribed medications were topical steroids and antihistamines, followed by emollients (32.09% and 15.81%, respectively). Viral infections were the most reported complaint (22.26%) and only two patients complained of erythema multiforme (0.66%).

Conclusion: This study found that the majority of cases could have been managed by family physicians at a primary care setting. Also, epidemiological seasonal variations were observed where the majority of patients requiring further management had presented during the autumn season.

Background: Deep neck space infection (DNSI) is an acute and severe condition, with severe cases being relatively rare but considerably more critical. Consequently, in clinical practice, there is a limited understanding and lack of comprehensive reviews on severe DNSI.

Methods: We conducted a retrospective analysis of the diagnosis and treatment of five cases of severe DNSI admitted to our department.

Results: All five patients were diagnosed via neck CT and surgical exploration. Bacterial cultures predominantly revealed mixed infections of Klebsiella and other gram-negative bacilli, along with anaerobic bacteria. Three patients had diabetes, two presented with diabetic ketoacidosis, and three had mediastinal involvement. Three patients underwent tracheotomy, while two required tracheal intubation. All patients were treated with neck incision, drainage, regular dressing changes, and targeted antibiotic therapy. They had an average hospital stay of 35.8 days, and all were discharged fully recovered.

Conclusion: Severe DNSI tends to occur in patients with diabetes and other underlying systemic conditions. Infections involving multiple deep neck spaces, such as the parapharyngeal, pretracheal, and prevertebral spaces, leading to high-risk complications like airway obstruction, cervical necrotizing fasciitis, mediastinitis, and sepsis, are considered severe DNSI. Early diagnosis, timely surgical exploration, drainage to maintain airway patency, and targeted antibiotic therapy are crucial to effective management.

Introduction: Snakebite is a serious and potentially fatal public health concern, especially in tropical and subtropical regions, leading to severe complications. The World Health Organization (WHO) identified snakebite as a Neglected Tropical Disease (NTD) in 2017 and launched a global campaign in 2019 with the goal of halving the number of snakebite-related deaths and disability cases by half by the year 2030.

Case presentation: A 26-year-old farmer male presented with a snake bite and soon developed neurological complications, including diplopia, seizures, and altered mental status with Glasgow coma scale(GCS) of 11 out of 15. Investigations revealed coagulation abnormalities and magnetic resonance venography showed acute thrombosis of the superior sagittal sinus. The patient was diagnosed with superior sagittal sinus thrombosis. He was admitted to the intensive care unit and treated with anticoagulants to manage the thrombus, prevent further clot formation, and administer seizure medications to control any potential seizures associated with the condition. Moreover, we closely monitored the patient's condition to ensure effective treatment and to address any complications that may arise. Throughout the next three days, the patient's health gradually improved due to supportive care. He was extubated and transferred to the general ward. He was discharged after 10 days, having made a full recovery.

Conclusion: This case report from Somalia emphasizes the importance of recognizing and managing superior sagittal sinus thrombosis as a rare but life threatening consequence of snake bite envenomation, particularly in resource-limited settings where access to advanced diagnostic and treatment modalities may be limited. If a patient experiences headache, impaired vision or seizures, after a snake bite, it is important to be highly suspicious of cerebral vascular complications including venous sinus thrombosis. Moreover, we recommend that a national study be conducted to identify the prevalent snake species in the region and to determine their specific habitats.

This preliminary study was a rapid retrospective analysis of out-of-hospital cardiac arrest (OHCA) cases from Baltimore City between January 2020 and December 2022, using data from the Cardiac Arrest Registry to Enhance Survival. Of the 1,282 cases in 2022, 27.4% received bystander CPR compared to 40.7% in Maryland and 40.8% nationwide. These findings suggest individuals experiencing OHCA in Baltimore City are 45% less likely to receive bystander CPR. Despite community education initiatives and dispatch-assisted protocols, the low bystander CPR rate indicates significant barriers to intervention. Addressing these disparities may necessitate a health equity-focused investigation into public awareness, CPR training access, and sociocultural factors.

Objective: We aimed to determine the association between hospital mortality of patients under investigation (PUI) for COVID-19 and emergency department length of stay (EDLOS).

Patients and methods: A retrospective study was conducted from April 3, 2020 to April 2, 2022. Adult PUI who presented with both clinical and epidemiological risk factors for COVID-19 disease and underwent sample collection with nasal swab for reverse transcription polymerase chain reaction were included in the study. The factors associated with EDLOS and hospital mortality were investigated using univariate logistic regression and multivariate logistic regression analyses.

Results: A total of 961 PUI were enrolled that included 836 (87%) non-COVID-19 patients. The median (interquartile range [IQR]) EDLOS durations for 7-day and 30-day mortality of all PUI were 3.1 hours (2.1,4.3, P = 0.231) and 3.2 hours (2.1,4.3, P = 0.653). Multivariate logistic regression analysis revealed that the significant factors associated with EDLOS longer than 4 hours were consultation of three departments (adjusted odds ratio (aOR) 27.3, 95% CI 2.42-309.71, P = 0.007), emergency severity index (ESI) level 3 (aOR 2.31, 95% CI 1.37-3.9), investigations >2 (aOR 2.62, 95% CI 1.62-4.25), nebulization (aOR 2.34, 95% CI 1.39-3.96), administration of intravenous fluid (aOR 2.62, 95% CI 1.59-4.33), performing ≥1 procedure (aOR 3.35, 95% CI 1.51-7.43), and discharged patients (aOR 2.13, 95% CI 1.02-4.48).

Conclusion: The significant factors associated with prolonged EDLOS in PUI included consultation of three departments, ESI level 3, investigations >2, ED treatment, ED procedures, and discharged patients. The median times of EDLOS and hospital LOS were 3.2 hours and 5.7 days. The EDLOS had no significant association with short-term mortality.

Background: Biliary ultrasound is often utilized in the evaluation of abdominal pain in the Emergency Department (ED). Common bile duct (CBD) identification is traditionally a standard component of the biliary ultrasound examination but can be challenging to perform for the novice sonographer. Previous work has demonstrated that CBD dilatation is rare in cases of cholecystitis with normal liver function tests (LFTs). We sought to assess the frequency of CBD dilatation in the subset of ED patients undergoing hepatobiliary ultrasound who have normal LFTs and an absence of gallstones or biliary sludge on ultrasound. We also performed an assessment of changes in CBD diameter by age and cholecystectomy status.

Methods: This was a retrospective chart review at a single academic ED. Patients were enrolled in the study if they underwent a radiology performed (RP) hepatobiliary ultrasound within the 2 year study period. Records were reviewed for the presence of gallstones or sludge, CBD diameter, age, clinical indication for the ultrasound, and LFTs. Descriptive analyses were performed, and interobserver agreement among data abstractors was assessed by K analysis for the presence of CBD dilatation. The Mann-Whitney test was utilized to assess statistical significance in the comparison of differences between CBD diameters amongst age groups.

Results: Of 1929 RP hepatobiliary ultrasounds performed in the study period, 312 were excluded and 1617 met inclusion criteria. Amongst these, there were 506 patients who had normal LFTs and an ultrasound with no stones or sludge. Ten patients within this group had a dilated CBD > 7 mm (1.98%, 95% CI of 1.08% to 3.6%). We also noted a statistically significant increase in CBD size in the older age cohort and in those individuals with a history of cholecystectomy.

Conclusion: CBD dilation in ED patients who present with normal LFTs and an absence of gallstones and biliary sludge is rare. Physicians should be reassured that the routine identification of the CBD on ultrasound in this setting is of low yield and need not be pursued.

Purpose: Point-of-care ultrasound (POCUS) helps emergency department (ED) physicians make prompt and appropriate decisions, but the optimal diagnostic integration and potential clinical benefits remain unclear. We describe the protocol and statistical analysis plan for a randomized controlled trial. The objective is to determine the effect of a POCUS-driven diagnostic pathway in adult dyspneic ED patients on the proportion of patients having a hospital stay of less than 24 hours when compared to the standard diagnostic pathway.

Patients and methods: This is a multicenter, randomized, investigator-initiated, open-labeled, pragmatic, controlled trial. Adult ED patients with chief complaint dyspnea are eligible. Patients are randomized (1:1) to the POCUS-driven diagnostic pathway or standard diagnostic pathway, with 337 patients in each group. The primary outcome is the proportion of patients having a hospital stay (from ED arrival to hospital discharge) of less than 24 hours. Key secondary outcomes include hospital length-of-stay, 72-hour revisits, and 30-day hospital-free days.

Conclusion: Sparse evidence exists for any clinical benefit from a POCUS-integrated diagnostic pathway. The results from this trial will help clarify the promising signals for POCUS to influence patient care among ED patients with dyspnea.

Background: Acute large vessel occlusion stroke (LVOS) requires swift and precise assessment for effective treatment. The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) protocol shows promise for rapid LVOS evaluation but lacks extensive validation. This study aims to assess the accuracy of FAST-ED in predicting LVOS and compare its predictive capability with the National Institute of Health Stroke Scale (NIHSS).

Methods: This prospective cross-sectional study was conducted at Thammasat University Hospital. Participants included those aged 18 years or older who presented with symptoms of acute stroke syndrome within 24 hours of onset. The study focused on comparing FAST-ED assessments by emergency department physicians with NIHSS evaluations by neurologists, followed by vascular imaging, which included brain multiphase CT angiography, MRI with MRA, and transcranial Doppler ultrasound combined with carotid Doppler ultrasound. Statistical analyses included the use of AuROC to assess the effectiveness of FAST-ED and to compare FAST-ED with NIHSS.

Results: 130 patients were included in the analysis, with 47 diagnosed with LVOS. No significant differences were found in most baseline characteristics between LVOS and non-LVOS groups, except for a higher prevalence of atrial fibrillation and lower systolic blood pressure in the LVOS group. The FAST-ED scale demonstrated a fair ability to predict LVOS with an AuROC of 0.79 (95% confidence interval (CI); 0.70, 0.87). A FAST-ED cut point of ≥4 showed improved specificity and likelihood ratio. Comparing FAST-ED≥4 with NIHSS≥6 revealed similar AuROC (0.74, 95% CI; 0.65, 0.82 and 0.72, 95% CI; 0.64, 0.80, respectively), with no significant statistical difference (p=0.661).

Conclusion: FAST-ED scale, especially with a cut-off point of ≥4, exhibits fair overall accuracy in predicting LVOS in patients who presented with suspected acute stroke within 24 hours at the ED. This predictive capability is closely comparable to that of the NIHSS at a cut-off point of ≥6.

Background: Uganda has a high incidence of road traffic accidents and high mortality rates, yet lacks a mature prehospital emergency care system. Our study addresses this gap by assessing the experiences, training, and confidence in providing first aid (FA) among diverse layperson first responders in Northern Uganda, expanding beyond previous research, which was limited to Central Uganda and specific occupational groups.

Methods: We conducted a cross-sectional survey among layperson first responders of various occupations in Gulu City, Acholi sub-region, Uganda. Data on socio-demographics, training, experiences, knowledge, and confidence in FA were collected.

Results: We included 396 participants, of whom 81.6% (n=323) were male, 47.0.6% (n=186) were aged 21-30 years, 59.3% (n=235) had obtained a secondary level of education, 23.7% (n=94) were commercial motorcyclists, and 45.7% (n=181) had work experience of >5 years. The majority (85.4%, n=338) had witnessed acute illness/trauma. Accidents/bleeding were the most commonly witnessed cases (68.6%, n=232), followed by burn injuries (10.1%, n=34). Most participants (52.3%, n=207) had attended FA training. Only 20.5% (n=81) had obtained an above-average score (≥70%). The majority (67.9%, n=269) were confident in providing FA. Lack of knowledge and skills (61.4%, n=78), fear of taking health risks (18.9%, n=24), and legal implications (7.1%, n=9) were the major reasons for not being willing to confidently give FA. Factors associated with above-average knowledge were tertiary education and being confident in providing FA, while training in FA and prior experience in giving FA were associated with confidence in giving FA.

Conclusion: In this study, laypeople in Northern Uganda exhibited a high level of FA training. However, low confidence in providing FA is attributed to inadequate knowledge, fear of health risks, and legal concerns. Therefore, future efforts should focus on assessing FA practices in diverse regions and promoting formal FA training.