JEM reports最新文献

英文中文

Physician-driven early evaluation: Encounters seen in a vertical model 医生驱动的早期评估:在垂直模型中看到的遭遇

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100028

Nicole R. Hodgson , Soroush Saghafian , Molly C. Klanderman , Andrej Urumov , Stephen J. Traub

Background

Although many emergency departments (EDs) employ some form of vertical patient flow, there is limited published literature describing variations of vertical pathways.

Objectives

We sought to describe our ED's emergency physician (EP)-driven vertical model and to characterize patients selected by EPs to be seen in our vertical space.

Methods

We retrospectively reviewed all vertical ED encounters in the study period, separately analyzing those who eventually received an ED bed (“ED Bed”) and those who were discharged without being roomed (“Vertical only”). We report patient demographics, ESI, vital signs, oxygen use, chief complaints, resource utilization, ED LOS, disposition, and 72 h return rates.

Results

Physicians elected to perform initial evaluations of a variety of patients in the vertical space. The two most common classes of complaints evaluated in the vertical space were extremity issues (21.4%) and skin complaints (13.5%). Patients presenting with abdominal pain and chest pain initially assessed in vertical were significantly more likely to later receive an ED bed (Standardized Difference of 38% and 21.4% respectively), and patients with skin complaints were more frequently discharged from the vertical space and were less likely to receive an ED bed (Standardized Difference of 32.2%). Most (56.2%) Vertical only patients were ESI 3, although EPs also discharged ESI 2, 4, and 5 patients from Vertical.

Conclusions

EP-driven patient selection for a vertical pathway allowed EPs to discharge some patients without bed placement while simultaneously functioning as their own triage physicians for higher-acuity patients who would go on to receive an ED bed.

背景尽管许多急诊科（ED）采用了某种形式的垂直患者流，但描述垂直路径变化的已发表文献有限。目的：我们试图描述急诊科的急诊医生（EP）驱动的垂直模型，并描述EP选择的在我们的垂直空间中就诊的患者的特征。方法我们回顾性分析了研究期间所有的垂直ED患者，分别分析了最终使用ED床（“ED床”）和未入住就出院的患者（“仅垂直”）。我们报告了患者人口统计、ESI、生命体征、氧气使用、主要投诉、资源利用率、ED LOS、处置和72h回报率。结果医生选择在垂直空间对各种患者进行初步评估。在垂直空间中评估的两类最常见的主诉是四肢问题（21.4%）和皮肤主诉（13.5%）。最初在垂直空间评估的腹痛和胸痛患者后来接受ED床的可能性明显更大（标准化差异分别为38%和21.4%），有皮肤病的患者更频繁地从垂直空间出院，不太可能接受ED床（标准化差异为32.2%）。大多数（56.2%）仅垂直空间的患者是ESI 3，和5名来自垂直路径的患者。结论EP驱动的垂直路径患者选择允许EP在不放置床位的情况下让一些患者出院，同时作为他们自己的分诊医生，为将继续接受ED床位的高视力患者进行分诊。

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引用次数: 1

Changes in adult trauma at a level 1 trauma center before and during the COVID-19 pandemic 在COVID-19大流行之前和期间，一级创伤中心成人创伤的变化

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100024

Garcia A , Walter D , Chan H K , Walia S , Hoot N , Huebinger R , Ugalde I , Chavez S

Background

Prior research has shown the COVID-19 pandemic is associated with changes in ED volumes, trauma caseloads and distribution of disease.

Objectives

We aim to characterize the impact of the COVID-19 pandemic at a diverse, high-volume Level 1 trauma center in the US.

Methods

We performed a retrospective review of our institutional trauma registry at our center from 2018 through 2021 to study changes before and after COVID-19. We established March 14 – December 31 as the study period of interest for each year. We analyzed the data with descriptive statistics and created Poisson regression models to determine the estimated percentage year-to-year changes.

Results

Total number of trauma cases increased with each subsequent year from 2018 (N = 4605) to 2021 (N = 7331) (total N = 23,727). In general, the proportion of Black or African American patients increased over time (2018: 19.2%, 2021: 23.0%). The proportion of patients insured by Medicaid (8.0% vs 10.5%) and Medicare (26.5% vs 32.8%) increased from 2018 to 2021. Comparing 2019 to 2020, we found increases in violent traumas: GSW (+88.6%, 95% CI 63.8%–117.2%) and stabbings (+39.6%, 95% CI 8.1%–80.3%). Trauma patient ED LOS decreased from 300 min (67–400 IQR) in 2018 to 249 min in 2021 (104–510 IQR).

Conclusion

This analysis identified increased trauma volumes, especially violent trauma (GSW, stabbing, other penetrating). There was a greater proportion of Black/African American patients and those insured with Medicare or Medicaid during the pandemic. TED LOS decreased over time while ED mortality and hospital LOS remained stable.

背景先前的研究表明，新冠肺炎大流行与ED数量、创伤病例数和疾病分布的变化有关。目的我们旨在描述新冠肺炎大流行对美国一个多样化、高容量的1级创伤中心的影响。方法我们对2018年至2021年我们中心的机构创伤登记进行了回顾性审查，以研究新冠肺炎前后的变化。我们将每年的3月14日至12月31日确定为感兴趣的研究期。我们用描述性统计分析了数据，并创建了泊松回归模型，以确定估计的逐年变化百分比。结果自2018年以来，创伤病例总数逐年增加（N=4605）至2021（N=7331）（总N=23727）。总的来说，黑人或非裔美国人患者的比例随着时间的推移而增加（2018年：19.2%，2021年：23.0%）。从2018年到2021年，医疗补助（8.0%对10.5%）和医疗保险（26.5%对32.8%）保险的患者比例增加。与2020年相比，我们发现暴力创伤增加：GSW（+88.6%，95%CI 63.8%-117.2%）和刺伤（+39.6%，95%CI8.1%-80.3%）。创伤患者ED LOS从300下降2018年最低（67–400 IQR）至249分钟（104–510 IQR）。结论该分析发现创伤量增加，尤其是暴力创伤（GSW、刺伤、其他穿透）。在疫情期间，黑人/非裔美国人患者以及参加医疗保险或医疗补助的患者比例更高。随着时间的推移，ED LOS下降，而ED死亡率和医院LOS保持稳定。

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引用次数: 1

Iatrogenic unilateral ureteral urinoma: A case report 医源性单侧输尿管尿瘤1例

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100037

Iran Alonso , Faith Quenzer , Alan Araiza , Micah Wittler

Background

Urinomas are encapsulated urine collections that result from obstruction, trauma, or iatrogenic instrumentation to the pelvicalyceal system, which may occur during gynecologic surgery.

Case report

We present a case of a large space occupying urinoma resulting from iatrogenic, unilateral ureteral injury following a hysterectomy five weeks prior to presentation in an adult woman. We review management, diagnostic imaging tests, and visual characteristics of urinomas found diagnostic imaging.

Why should the emergency medicine physician be aware of this?

The emergency physician should consider ureteral injury after gynecological surgery, if there are complaints of urinary obstruction and multiple attempts of Foley catheter placement with little or no urinary output. Although, a non-contrasted CT scan can be used to diagnose the urinoma, a CT scan with delayed IV contrast may improve the overall image quality and diagnoses when suspecting a large obstructing mass such as a urinoma.

背景:尿膜瘤是由骨盆骨盆系统梗阻、创伤或医源性内固定引起的包裹性尿液收集，可能发生在妇科手术中。病例报告:我们报告一例因医源性单侧输尿管损伤而导致的大占位性尿路瘤，患者为成年女性，在就诊前5周行子宫切除术。我们回顾诊断性影像学检查的处理、诊断性影像学检查和尿瘤的视觉特征。急诊医师为什么要意识到这一点?妇科手术后，如果有尿路梗阻的主诉，多次尝试放置Foley导尿管，但尿量很少或没有输出，急诊医生应考虑输尿管损伤。虽然，非对比CT扫描可用于诊断尿路瘤，但当怀疑尿路瘤等较大的阻塞物时，延迟静脉对比的CT扫描可提高整体图像质量和诊断。

引用次数: 0

Bilateral renal and splenic infarction secondary to atrial fibrillation: A case report 继发于心房颤动的双侧肾脾梗死1例

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100018

Danielle Abou Khater, Rafi Daou, Alain Khoury, Ramzi Nakhle

Background

Renal and splenic infarctions are uncommon medical conditions, and their diagnosis can often be challenging. We describe a rare case of bilateral renal and splenic infarction secondary to atrial fibrillation.

Case report

A 58-year-old woman with a past medical history of hypertension and paroxysmal atrial fibrillation presented to the ED with epigastric pain, nausea, and multiple episodes of vomiting. Her electrocardiogram showed atrial fibrillation. However, upon review of her home medications, she was not taking any anticoagulants. Laboratory tests showed an elevated lactate dehydrogenase. Contrast-enhanced CT scan of her abdomen and pelvis revealed bilateral wedge-shaped areas of parenchymal hypo-enhancement in both kidneys and in the spleen. She was diagnosed with bilateral renal and splenic infarction and was admitted to the hospital. She was treated with IV heparin and discharged on long term anticoagulation after an uneventful stay.

Why should an emergency physician be aware of this?

This case demonstrates a rare case of bilateral renal and splenic infarction secondary to atrial fibrillation and emphasizes the importance of maintaining a high clinical suspicion for solid organ infarction in patients with high risk of thromboembolic events, as early recognition and treatment are key in reducing morbidity and mortality.

背景肾脏和脾脏梗死是一种罕见的疾病，其诊断往往具有挑战性。我们描述了一例罕见的继发于心房颤动的双侧肾和脾梗死。病例报告：一名58岁女性，既往有高血压和阵发性心房颤动病史，在急诊科就诊时伴有上腹痛、恶心和多次呕吐。她的心电图显示心房颤动。然而，在检查了她的家庭药物后，她没有服用任何抗凝血剂。实验室测试显示乳酸脱氢酶升高。腹部和骨盆的CT增强扫描显示，双侧肾脏和脾脏的楔形实质低增强区。她被诊断为双侧肾和脾梗死，并被送入医院。她接受了静脉注射肝素治疗，并在平静的住院后通过长期抗凝治疗出院。为什么急诊医生应该意识到这一点？该病例显示了一例罕见的继发于心房颤动的双侧肾和脾梗死病例，并强调了在血栓栓塞事件高危患者中保持对实体器官梗死的高度临床怀疑的重要性，因为早期识别和治疗是降低发病率和死亡率的关键。

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引用次数: 0

Cytomegalovirus-associated myelitis in an emergency department patient with altered mental status 精神状态改变急诊科患者巨细胞病毒相关性脊髓炎1例

JEM reports

Pub Date : 2023-06-01 DOI: 10.1016/j.jemrpt.2023.100025

Hayley Naasz , Emily J. White , Rebecca G. Theophanous

Background

Cytomegalovirus (CMV) of the Herpesviridae family can occur in immunocompromised patients, including those with human immunodeficiency virus (HIV) and CD4 counts below 200 cells/microL. CMV-associated acute transverse myelitis is rare and can present with acute sensory changes, ascending weakness, and sphincter dysfunction.

Case report

A middle-aged female with uncontrolled HIV presented with altered mental status, inability to walk, and incontinence. On examination, she was significantly altered with focal neurological findings including nystagmus, bell's palsy, urinary retention, and leg weakness and numbness. Lumbar puncture results were positive for CMV infection, with transverse myelitis on magnetic resonance imaging, requiring hospital admission and treatment with ganciclovir. Unfortunately, her hospital course was complicated by immune-reconstitution inflammatory syndrome after initiation of antiretroviral medications, with prolonged significant debilitation including sensorineural hearing loss, neurogenic bladder requiring catheterization, and difficulty walking after hospital discharge.

Why should an emergency medicine physician be aware of this?

CMV infection presenting with both cranial and peripheral neuropathic involvement is a unique manifestation. Physicians should also recognize the diagnostic criteria for acute transverse myelitis, including spinal cord sensorimotor and autonomic dysfunction, a clearly defined sensory level, bilateral distribution, and inflammation noted on magnetic resonance imaging. This case highlights the importance of maintaining a broad differential in patients who present with altered mental status and performing a comprehensive neurological examination. In summary, physicians should quickly recognize the neurological findings of CMV infection and start urgent treatment to prevent permanent functional, neurological, and cognitive damage, especially in patients with HIV or immunocompromised status.

背景:疱疹病毒科巨细胞病毒(CMV)可发生在免疫功能低下的患者中，包括人类免疫缺陷病毒(HIV)患者和CD4细胞计数低于200细胞/微升的患者。巨细胞病毒相关的急性横贯脊髓炎是罕见的，可表现为急性感觉改变，上升无力和括约肌功能障碍。病例报告:一名中年女性HIV感染不受控制，表现为精神状态改变，不能行走，尿失禁。检查时，她的局灶性神经学表现明显改变，包括眼球震颤、贝尔氏麻痹、尿潴留、腿部无力和麻木。腰椎穿刺结果为巨细胞病毒感染阳性，磁共振成像显示为横贯脊髓炎，需要住院并使用更昔洛韦治疗。不幸的是，在开始抗逆转录病毒药物治疗后，她的住院过程因免疫重建炎症综合征而变得复杂，并伴有长期的明显虚弱，包括感音神经性听力丧失，神经源性膀胱需要导尿，出院后行走困难。急诊医生为什么要意识到这一点?巨细胞病毒感染表现为颅脑和周围神经病变累及是一种独特的表现。医生还应认识到急性横断面脊髓炎的诊断标准，包括脊髓感觉运动和自主神经功能障碍，明确定义的感觉水平，双侧分布和磁共振成像记录的炎症。本病例强调了在出现精神状态改变的患者中保持广泛鉴别和进行全面神经学检查的重要性。总之，医生应该迅速认识到巨细胞病毒感染的神经学表现，并开始紧急治疗，以防止永久性的功能、神经和认知损伤，特别是在艾滋病毒或免疫功能低下的患者中。

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引用次数: 0

Physician-driven early evaluation: Encounters seen in a vertical model 医生驱动的早期评估:在垂直模型中看到的遭遇

JEM reports

Pub Date : 2023-04-01 DOI: 10.1016/j.jemrpt.2023.100028

N. Hodgson, S. Saghafian, M. Klanderman, A. Urumov, S. Traub

引用次数: 1

Bilateral renal and splenic infarction secondary to atrial fibrillation: A case report 继发于心房颤动的双侧肾脾梗死1例

JEM reports

Pub Date : 2023-04-01 DOI: 10.1016/j.jemrpt.2023.100018

Danielle Abou Khater, Rafi Daou, Alain Khoury, Ramzi Nakhle

引用次数: 0

Emergent pharmacological management of ulnar artery thrombosis 尺动脉血栓形成的紧急药物治疗

JEM reports

Pub Date : 2023-04-01 DOI: 10.1016/j.jemrpt.2023.100019

Henry Zou, Bethany Beard

引用次数: 0

Trends in interhospital transfer volume by season, weekday, time of day, and federal holiday status 按季节、工作日、一天中的时间和联邦假日状态的医院间转诊量趋势

JEM reports

Pub Date : 2023-04-01 DOI: 10.1016/j.jemrpt.2023.100026

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引用次数: 0

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JEM reports

Pub Date : 2023-03-01 DOI: 10.1016/j.jemrpt.2023.100013

John M. Bowling, Robert Stenberg, Andrew Hill

引用次数: 0

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