American Journal of Emergency Medicine最新文献

Diagnosis of cryptococcal meningitis is typically aided through CSF analysis obtained via lumbar puncture (LP), revealing elevated WBCs, increased protein, decreased glucose, and increased opening pressure. While CSF culture confirms the diagnosis, it takes days, prompting reliance on these adjuncts. AIDS from Human Immunodeficiency Virus is less commonly diagnosed in the emergency setting due to advances in testing and treatment. This case highlights fungal meningitis in an undiagnosed AIDS patient, where positive CSF cryptococcal antigen enabled timely diagnosis despite normal CSF findings, emphasizing the importance of rapid diagnostic tests in high-risk patients even when CSF results appear normal. A 30-year-old male with no prior medical history presented with 3.5 weeks of nausea, vomiting, headache, and back pain. He showed signs of cachexia, photophobia, and neck stiffness. Initial CSF analyses were within normal limits for glucose, WBC, and protein, but cryptococcal antigen was positive. He was treated with amphotericin B and flucytosine. CSF cultures confirmed C. neoformans, and serial LPs monitored elevated opening pressures, requiring a VP shunt. The patient was diagnosed with AIDS (CD4 6 cells/mm³). This case underscores that C. neoformans can present with normal CSF studies, delaying diagnosis and treatment, highlighted by the fact that this patient went undiagnosed in the preceding 3.5 weeks. CSF cryptococcal antigen and opening pressure are critical diagnostic tools, enabling timely antifungal therapy. Given the high mortality rate, early empirical treatment is essential, especially in high-risk patients, even when CSF findings seem normal.

Objective: Fibrinolysis is generally considered an alternative to percutaneous coronary intervention (PCI) for ST-Segment Elevation Myocardial Infarction (STEMI) when PCI is not immediately feasible. The COVID-19 pandemic may have impacted the timeliness of PCI. We sought to compare the rate of fibrinolysis use before vs. during the COVID-19 pandemic in US emergency departments (EDs). Characteristics of patients and EDs with fibrinolysis use prior to vs. during the COVID-19 pandemic were also compared.

Methods: We identified adult patients presenting to US EDs for STEMI using the Nationwide Emergency Department Sample (NEDS) database. The cohort was restricted to individuals receiving fibrinolysis. Patients were divided into two cohorts based on receipt of fibrinolysis during the pre-pandemic (April 2018-December 2019) and pandemic (April 2020-December 2021) time periods.

Results: In the period prior to the COVID-19 pandemic, fibrinolysis use was identified in 1593 ED encounters, representing a rate of 24.5 per 1000 STEMI encounters in the database. In the COVID-19 pandemic period, fibrinolysis use was identified in 1700 encounters, representing a rate of 28.2 per 1000 STEMI encounters in the database. This corresponded to a rate difference of 3.7 per 1000 STEMI encounters (95 % confidence interval: 1.9-5.5, p < 0.001). Most ED and patient characteristics were similar prior to vs during the pandemic among included cohorts.

Conclusions: Fibrinolytic therapy use increased, but only slightly, during the COVID-19 pandemic. This suggests that the healthcare system adapted quickly to changes during the pandemic in the setting of STEMI treatment.

Background: Gastrointestinal symptoms of acute opioid withdrawal are distressing for patients and are often difficult to manage with conventional therapies. Insufficiently managed opioid withdrawal symptoms may lead patients to leave against medical advice, which can increase their risk of relapse and result in poor outcomes from untreated conditions. We assessed the impact of an erector spinae plane block on the acute gastrointestinal symptoms of opioid withdrawal.

Case report: A 44-year-old woman with opioid use disorder presented to the ED with severe gastrointestinal symptoms of opioid withdrawal, refractory to parenteral opioid agonists and symptomatic treatment. She underwent an ultrasound-guided erector spinae plane block with 30 mL of 0.25 % bupivacaine which completely resolved her gastrointestinal symptoms.

Conclusion: Through blockade of the sympathetic chain, the erector spinae plane block could provide targeted symptomatic relief for patients presenting with severe gastrointestinal symptoms of opioid withdrawal. Future research should seek to evaluate the efficacy observed in this case in larger patient populations.

Aim: This study aims to evaluate the impact of serum magnesium (Mg) level on hospitalization and 28-day mortality in a nonspecific geriatric patient population.

Method: This single-center retrospective and observational clinical study involved patients aged over 70 years who presented to the emergency department for any complaint. Those whose Mg levels were not assessed and those who presented due to trauma, treated in another hospital before coming to our hospital, presented in cardiopulmonary arrest, refused treatment and/or left the hospital without permission, and were referred to another hospital were excluded from this study. The patients were classified as having hypomagnesemia (≤1.7 mg/dL Mg), normomagnesemia (1.7-2.2 mg/dL), and hypermagnesemia (≥2.2 mg/dL). We assessed whether patients between these groups could provide data on hospitalization, discharge, and 28-day mortality.

Results: The average age of the included patients was 77.11 ± 7.91 years. Of the patients, 1032 (55.3 %) were female. The incidence rates of hypomagnesemia, normomagnesemia, and hypermagnesemia significantly differed between the hospitalized and discharged patients (p < 0.01). In older patients, hypermagnesemia was associated with hospitalization. Moreover, a significant difference in Mg levels at 28 days was observed between the deceased patients and survivors (p < 0.001); hypermagnesemia was significantly more common among the deceased patients. The results of the univariate and multivariate regression analyses showed that hypermagnesemia was a significant factor for discharge at 28 days (p < 0.001).

Conclusion: While hypomagnesemia is more manageable than hypermagnesemia, the latter is an important predictor of hospitalization and 28-day mortality in individuals over 70 years old.

Background: Trauma is the leading non obstetric cause of death in pregnant women. Pregnancy above 20 weeks falls under special considerations group in the Center for Disease Control and Prevention (CDC) field triage criteria. Trauma centers' designation level in the United States is based on available resources for care.

Aim: In this study, we examine the association between trauma center designation level and survival of pregnant patients presenting to the Emergency Department (ED) after a traumatic injury.

Methods: This retrospective observational study included all pregnant women of reproductive age (16 years and above) who experienced any form of trauma and were registered in the National Trauma Data Bank 2020 dataset. Descriptive analysis was carried out. All variables were stratified by the trauma designation levels. Firth logistic regression was conducted to examine the association between trauma designation levels and survival to hospital discharge after controlling for all potential confounding factors.

Results: A total of 1612 patients were included in this study. The average age was 27.2 (±6.9 years). Most patients were taken to level I (58.3 %) and II (33.9 %) centers. Overall survival of patients after pregnancy trauma was 97.2 %. After adjusting for confounders, patients taken to level II and III trauma centers had similar survival to hospital discharge compared with those taken to level I centers [OR = 2.561, 95 % CI: 0.644-10.182 and OR = 4.886, 95 % CI: 0.584-40.862 respectively].

Conclusion: In this study, trauma center designation level did not impact survival of pregnant patients sustaining injuries. This provides further evidence that the CDC's field triage guidelines, including their specific considerations for pregnant patients are accurate and that the current practice seems to be effective.

Background: Critically ill ED patients on life support may undergo transition to comfort care as decided by the surrogate decision maker. When several hours are needed for loved ones to arrive and say farewell before initiating comfort care ("delayed comfort care"), these patients require prolonged ED stays or costly intensive care unit (ICU) admissions.

Methods: A novel ED observation unit (EDOU)-based delayed comfort care pathway for ED patients on invasive mechanical ventilation and/or vasopressors was created in 2013 at Stanford Hospital. Inclusion criteria are: agreement by the surrogate decision maker to no titration of life support and initiation of comfort care within 18 h of EDOU admission. Exclusion criteria are: potential for organ donation and lack of a private room or nursing resources in the EDOU. Feasibility was assessed by analyzing the electronic health record for all patients who utilized the pathway between 8/2013 and 2/2023. The primary outcome was the proportion of patients who had initiation of comfort care after all expected loved ones arrived to the bedside. We also analyzed patient characteristics, clinical operation data, and safety data.

Results: 23 patients were identified in the study cohort. The average patient age was 76, and 48 % were female. Three ED diagnoses for the cohort were intracranial hemorrhage (57 %), cardiac arrest (26 %), and respiratory failure (17 %). All patients were intubated, and six were also on vasopressors on arrival to the EDOU. 100 % of patients had all expected family members arrive to bedside prior to initiation of comfort care. All patients had initiation of comfort care within 18 h of EDOU admission (median time from EDOU arrival to extubation 1.1 h (IQR 0.2-3.2)). No patients had adverse events in the EDOU, died before comfort care initiation, or were transferred to ICU.

Conclusion: The EDOU-based delayed comfort care pathway is a feasible way to deliver compassionate end of life care for patients on life support. It can be considered in hospitals with an EDOU especially if their private ED beds and ICU resources are scarce.

Objective: To evaluate triage nurses' clinical judgment in determining short acting β2-agonist bronchodilator therapy need for children with shortness of breath in the pediatric emergency department, without prior physician assessment.

Methods: This prospective study compared decision-making between triage nurses and physicians regarding bronchodilator inhalation therapy necessity. Trained nurses assessed children aged 2-18 with shortness of breath, including history-taking, vital signs, and lung auscultation. Nurses made short acting β2-agonist therapy decisions based on predefined criteria. Pediatric specialists independently evaluated patients and recorded their decision.

Results: Analysis of 62 assessments from 31 patients showed no statistically significant difference between nurses and doctors in administering inhaled bronchodilators (nurses: 87.1 %, doctors: 83.9 %). Clinical sign detection was similar, except for tachypnea (nurses: 48.4 %, doctors: 71 %, P = 0.07). McNemar's test and Cohen's kappa coefficient demonstrated strong nurse-doctor correlation per patient (accuracy: 83.9 %, P = 0.1; kappa: 0.351).

Conclusions: Nurses excelled in recognizing certain clinical signs but showed lower compatibility in others. For severe cases, nurses consistently identified patients needing additional treatments.