JEM reports最新文献

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“You mean it's not cancer?”: Choledochoduodenal fistula, a rare cause of biliary obstruction "你是说这不是癌症？胆总管十二指肠瘘，胆道梗阻的罕见病因

JEM reports

Pub Date : 2024-07-11 DOI: 10.1016/j.jemrpt.2024.100107

Background

Choledochoduodenal fistula is a rare and poorly understood condition that results from the anomalous formation of a communicating tract between the common bile duct and the duodenum. While the precise etiology is not understood there has been a notable increase in identified cases in the last 20 years. The symptoms of choledochoduodenal fistula are vague and it is often not diagnosed until the patient develops cholangitis.

Case report

A 70yo M with a recent diagnosis of hepatitis C presented to the emergency department for evaluation of jaundice. Ultrasound demonstrated a hydropic gallbladder with “double duct” sign. The patient was admitted to the hospital and underwent ERCP. This identified a choledochoduodenal fistula which was treated. On follow up the patient had marked improvement with no significant sequelae or complications.

Why should an emergency physician be aware of this?

Choledochoduodenal fistula is a rare and poorly understood pathology. However, choledochoduodenal fistula “attacks” are strongly associated with cholangitis which has a mortality approaching 5 % even when appropriately managed (Sokal et al., Dec 2019) [1]. In our case, neither ultrasound nor portal vein-phased CT demonstrated the Choledochoduodenal fistula and ERCP was required both to identify and treat the fistula. In the setting of obstructive jaundice, it may be prudent for the emergency physician to consider transfer to a center with ERCP capability if it is not readily available in their facility.

背景胆总管十二指肠瘘是一种罕见的病症，由于胆总管和十二指肠之间的沟通管道异常形成，因此人们对这种病症知之甚少。虽然确切的病因尚不清楚，但在过去 20 年中，发现的病例明显增多。胆总管十二指肠瘘的症状很模糊，通常在患者出现胆管炎时才被诊断出来。病例报告：一名 70 多岁的男性患者最近被诊断出患有丙型肝炎，因黄疸到急诊科就诊。超声检查显示胆囊积水并伴有 "双管 "征。患者入院后接受了 ERCP 检查。检查发现了胆总管十二指肠瘘，并对其进行了治疗。为什么急诊医生应该注意这一点？胆总管十二指肠瘘是一种罕见的病理现象，人们对其了解甚少。然而，胆总管十二指肠瘘 "发作 "与胆管炎密切相关，即使得到适当处理，胆管炎的死亡率也接近 5%（Sokal 等人，2019 年 12 月）[1]。在我们的病例中，超声和门静脉相位 CT 均未显示胆总管十二指肠瘘，因此需要进行 ERCP 来识别和治疗瘘管。在出现阻塞性黄疸的情况下，如果急诊医生的医疗机构无法立即提供ERCP服务，则应谨慎考虑将患者转至具备ERCP服务的中心。

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引用次数: 0

Don't Be-RASH: A case report Don't Be-RASH：病例报告

JEM reports

Pub Date : 2024-07-11 DOI: 10.1016/j.jemrpt.2024.100105

Background

Bradycardia, renal failure, atrioventricular (AV) blockade, shock, and hyperkalemia is reported as a constellation of symptoms in critical care medicine known as “BRASH Syndrome.” It is reportedly a complex clinical scenario in which accumulated AV blockers and hyperkalemia result in bradycardia, renal failure, and shock interacting with each other synergistically.

Case report

A 70-year-old male taking metoprolol at home presented to the emergency department with hyperkalemia, cardiogenic shock, bradycardia, and renal failure. The patient was treated with routine treatment for shock (vasopressors), hyperkalemia (cardiac membrane stabilization, electrolyte temporization, and diuresis), and renal failure (dialysis) with eventual clinical resolution. A serum metoprolol concentration was obtained which was consistent with a therapeutic concentration. Why should the emergency physician be aware of this? The proposed BRASH syndrome may over-emphasize the role of AV nodal blockade in the presentation of patients with renal failure, hyperkalemia, and bradycardia. There is a limited list of renally-cleared medications that would be directly impacted by acute renal insufficiency. A common memory device for renally cleared beta blockers is NASA (nadolol, atenolol, sotalol, acebutolol). The suggestion of synergistic effect of hyperkalemia and therapeutic AV nodal blockade is speculative and lacks empiric evidence. The implication of potential supratherapeutic drug concentrations or even enhanced synergistic effects of a drug suggests a relative toxicity, which could mislead a clinician into considering toxicity state specific therapies such as high insulin euglycemia, glucagon, or lipid emulsion which carry adverse effect profiles and generally lack evidence to support use in these clinical presentations.

背景据报道，心动过缓、肾功能衰竭、房室（AV）传导阻滞、休克和高钾血症是重症医学中的一组症状，被称为 "BRASH 综合征"。据报道，这是一种复杂的临床情况，其中累积的房室传导阻滞剂和高钾血症会导致心动过缓、肾功能衰竭和休克，并相互协同作用。病例报告一名 70 岁的男性在家中服用美托洛尔，因高钾血症、心源性休克、心动过缓和肾功能衰竭而到急诊科就诊。患者接受了针对休克（血管加压药）、高钾血症（心膜稳定、电解质暂缓、利尿）和肾衰竭（透析）的常规治疗，最终临床症状缓解。获得的血清美托洛尔浓度符合治疗浓度。急诊医生为什么要注意这一点？拟议的 BRASH 综合征可能会过度强调房室结阻滞在肾衰竭、高血钾和心动过缓患者中的作用。急性肾功能不全会直接影响肾脏清除的药物清单有限。肾清除β受体阻滞剂的常用记忆装置是 NASA（纳多洛尔、阿替洛尔、索他洛尔、醋丁洛尔）。关于高钾血症与治疗性房室结阻滞协同作用的说法是推测性的，缺乏经验证据。潜在的超治疗药物浓度或甚至药物协同作用的增强暗示了药物的相对毒性，这可能会误导临床医生考虑毒性状态下的特定疗法，如高胰岛素优降糖、胰高血糖素或脂质乳剂，这些疗法具有不良反应特征，通常缺乏证据支持在这些临床表现中使用。

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引用次数: 0

Emergency medicine resident productivity during the SARS-CoV-2 disease 2019 (COVID-19) pandemic 2019 年 SARS-CoV-2 疾病（COVID-19）大流行期间急诊医学住院医师的工作效率

JEM reports

Pub Date : 2024-07-09 DOI: 10.1016/j.jemrpt.2024.100103

Background

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) pandemic disrupted medical education in many care settings, including the Emergency Department (ED). It is unclear what effects these changes have had on resident training and clinical productivity.

Objective

The purpose of this study is to determine Emergency Medicine (EM) resident productivity in the ED during the COVID-19 pandemic.

Methods

This was a retrospective observational study at an academic medical center with an EM residency program. Data were collected from the electronic medical record from 7/1/2017–10/31/2021. The primary outcome was patients per hour (PPH). Postgraduate year (PGY) 1 and 2 shifts were included. Analysis included descriptive statistics (mean ± standard deviation), correlation testing, and multivariate linear regression.

Results

Overall, PGY1 residents saw fewer PPH than PGY2 residents (1.00 ± 0.12 vs 1.40 ± 0.13 PPH, p < 0.001). During academic year (AY) 2019–2020, there was a trend towards lower resident productivity compared to pre-COVID (2017–2019) that was statistically significant at the PYG2 level (PGY1 0.96 ± 0.13, p = 0.06; PGY2 1.31 ± 0.10 PPH, p = 0.004). This difference resolved over the course of AY 2020–2021. Multivariate linear regression showed association of resident productivity with patient volume, month of residency, and year of residency.

Conclusion

The period surrounding the COVID-19 pandemic showed a trend towards decreased resident productivity during AY 2019–2020, which proved transient and resolved during AY 2020–2021. Resident productivity was associated with both month of training and ED volume. Additional research is needed to describe the long-term effects on the training environment during COVID-19 on physician productivity.

背景2019年严重急性呼吸系统综合征冠状病毒2（SARS-CoV-2）疾病（COVID-19）大流行扰乱了包括急诊科（ED）在内的许多医疗机构的医学教育。本研究旨在确定 COVID-19 大流行期间急诊科（EM）住院医师在急诊科的工作效率。数据收集自 2017 年 7 月 1 日至 2021 年 10 月 31 日的电子病历。主要结果是每小时病人数（PPH）。研究生年（PGY）1班和2班均包括在内。分析包括描述性统计（平均值±标准差）、相关性测试和多变量线性回归。结果总体而言，PGY1住院医师比PGY2住院医师看的PPH少（1.00±0.12 vs 1.40±0.13 PPH，p <0.001）。在2019-2020学年，与COVID前（2017-2019年）相比，住院医师生产率呈下降趋势，在PYG2水平上具有统计学意义（PGY1 0.96 ± 0.13，p = 0.06；PGY2 1.31 ± 0.10 PPH，p = 0.004）。这一差异在 2020-2021 学年期间有所缓解。多变量线性回归结果显示，住院医师的工作效率与患者数量、住院月份和住院年份有关。结论 COVID-19 大流行前后，2019-2020 学年住院医师的工作效率呈下降趋势，但这一趋势是短暂的，并在 2020-2021 学年得到缓解。住院医师的工作效率与培训月份和急诊室数量有关。需要开展更多研究，以描述 COVID-19 期间培训环境对医生工作效率的长期影响。

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引用次数: 0

A case of visceral angioedema diagnosed in the emergency department 一例在急诊科确诊的内脏血管性水肿病例

JEM reports

Pub Date : 2024-07-08 DOI: 10.1016/j.jemrpt.2024.100104

Negin Ceraolo , Megan Cook , Kristen Septaric , David Ceraolo , Erin Simon

Background

Angioedema is a non-pitting type of edema that involves subcutaneous tissue of the extremities, neck, face, lips, oral cavity, larynx, and gut that can be classified into hereditary or acquired forms. In the emergency department (ED), it is common for visceral angioedema to be undiagnosed due to similarity of presentation to other disorders.

Case Report

We present a case of a 65-year-old male with likely visceral angioedema due to underlying angiotensin-converting enzyme inhibitor use. He initially presented to an outside ED due to a nonspecific pruritic rash. He was discharged with a steroid prescription. The patient had another outside ED visit with the development of acute rapid facial swelling and shortness of breathing that progressed to respiratory distress. He was discharged again after a period of observation and treatment for anaphylaxis. Not long after, he developed gastrointestinal distress prompting his third visit to the ED, where he was diagnosed with visceral angioedema. Although the treatment of angioedema does not differ depending on the type, patients with more extensive presentation may require further monitoring.

Why should an emergency physician be aware of this?

Visceral angioedema is a rare complication and can easily be mistaken for other gastrointestinal pathology such as gastroenteritis. Emergency physicians need to understand the complexity of angioedema and the multiple organ systems that can be involved. Diligent review of patient medications and other historical factors that can cause angioedema and early treatment will lead to better outcomes for patients.

背景血管性水肿是一种非点状水肿，累及四肢、颈部、面部、嘴唇、口腔、喉部和肠道的皮下组织，可分为遗传性和获得性两种类型。在急诊科（ED），由于内脏血管性水肿的表现与其他疾病相似，因此未被诊断出来是很常见的。病例报告我们接诊了一例 65 岁男性患者，他很可能因服用血管紧张素转换酶抑制剂而出现内脏血管性水肿。他最初因非特异性瘙痒性皮疹到外面的急诊室就诊。出院时医生给他开了一张类固醇处方。患者再次到外面的急诊室就诊时，出现了急性快速面部肿胀和呼吸急促，并发展为呼吸困难。经过一段时间的观察和过敏性休克治疗后，他再次出院。不久后，他又出现了胃肠道不适，这促使他第三次来到急诊室，并被诊断为内脏血管性水肿。内脏血管性水肿是一种罕见的并发症，很容易被误诊为胃肠炎等其他胃肠道疾病。急诊医生需要了解血管性水肿的复杂性以及可能涉及的多个器官系统。仔细检查患者的用药情况和其他可能导致血管性水肿的历史因素，并及早治疗，将为患者带来更好的治疗效果。

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引用次数: 0

Page kidney induced emergent hypertension status post renal biopsy a case report 肾活检后肾脏诱发的突发高血压状态病例报告

JEM reports

Pub Date : 2024-07-08 DOI: 10.1016/j.jemrpt.2024.100102

Background

Page kidney is a rare cause of secondary hypertension arising from a subcapsular hematoma or mass compressing the kidney leading to increased arterial hypertension. Common causes of expansive kidney parenchymal bleeding are due to blunt trauma or less often iatrogenic causes, such as renal biopsy. Most of the time the secondary hypertension is resolved by evacuating the hematoma by stopping the bleeding via renal arterial embolization (RAE).

Case report

We discuss a 23-year-old female with a past medical history of hypertension, chronic kidney disease, status post left renal biopsy three days prior to evaluation who presented to the emergency department with severe left flank pain. From initial evaluation in the emergency department, a large expansive subcapsular hematoma was identified on imaging suggesting Page kidney causing the hypertensive emergency. The patient was managed with renal arterial embolization to control bleeding and blood pressure medications.

Why should an emergency physician be aware of this

Emergency physicians should be able to identify this rare cause of secondary hypertension to initiate proper management. Immediate blood pressure control, imaging and appropriate consultations should be initiated. Identifying sources of active bleeding is crucial for definitive management as was in the case which we presented. Quick identification of Page kidney is crucial to managing life threatening secondary hypertension, preventing renal failure, and addressing any sources of active hemorrhage.

背景性肾病是继发性高血压的一种罕见病因，由囊下血肿或肿块压迫肾脏导致动脉高血压升高引起。肾实质扩张性出血的常见原因是钝性外伤或较少见的先天性原因，如肾活检。大多数情况下，通过肾动脉栓塞（RAE）止血，排出血肿，继发性高血压即可缓解。病例报告我们讨论的是一名 23 岁女性，既往有高血压、慢性肾脏病病史，评估前三天曾接受过左肾活检，因左侧腹部剧烈疼痛到急诊科就诊。在急诊科进行初步评估后，影像学检查发现了一个巨大的膨胀性囊下血肿，表明是肾脏引起的高血压急症。为什么急诊医生应该注意这一点？急诊医生应该能够识别这种罕见的继发性高血压病因，以便采取适当的治疗措施。应立即进行血压控制、影像学检查和适当的会诊。与我们介绍的病例一样，确定活动性出血的来源对于明确治疗至关重要。快速识别肾脏是控制危及生命的继发性高血压、预防肾衰竭和处理任何活动性出血来源的关键。

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引用次数: 0

Can a negative d-dimer rule out pulmonary embolism in patients with COVID-19? d 二聚体阴性能否排除 COVID-19 患者的肺栓塞？

JEM reports

Pub Date : 2024-07-06 DOI: 10.1016/j.jemrpt.2024.100100

Background

Globally, there have been more than 771 million confirmed cases of COVID-19 and more than 6.9 million deaths. The relationship between Covid-19 and pulmonary embolism (PE) has been well-established.

Objectives

We evaluated the correlation between normal D-dimer levels and negative findings on computed tomography pulmonary angiogram (CTPA) to assess its predictive value. Additionally, we determined the sensitivity and specificity of a D-dimer in COVID-19 (+) patients.

Methods

This was a retrospective cohort study of all adult patients presenting to one of 17 EDs within a large integrated healthcare system between March 1, 2020, and December 31, 2021, who were diagnosed with COVID-19 and had a D-dimer and CTPA as part of their clinical workup. This study includes EDs in urban, suburban, and rural areas. Sensitivity and specificity were calculated to assess the performance of D-dimer tests in discriminating those with and without PE. Multiple logistic regression was used to assess the effect of D-dimer test results in predicting PE.

Results

A total of 3133 patients were included in this study (Fig. 1). Of 3133 patients, 2846 (91 %) had an abnormal D-dimer, and 287 (9 %) had a normal D-dimer. In the group with the abnormal D-dimer, 145 (5 %) had a PE on CTPA. In the group with the normal D-dimer, 285 (99.3 %) patients did not have a PE on CTPA. The sensitivity of D-dimer in this population was 98.6 %, and the specificity was 9.5 %. Patients with abnormal D-dimer levels were 7.86 times more likely to have a PE.

Conclusion

In conclusion, our study found that PE could be safely excluded for COVID-19 (+) patients with a normal or age-adjusted D-dimer.

背景全球已确诊的 COVID-19 病例超过 7.71 亿例，死亡人数超过 690 万。我们评估了 D-二聚体水平正常与计算机断层扫描肺血管造影（CTPA）阴性结果之间的相关性，以评估其预测价值。此外，我们还确定了 D-二聚体在 COVID-19 (+) 患者中的敏感性和特异性。方法这是一项回顾性队列研究，研究对象是 2020 年 3 月 1 日至 2021 年 12 月 31 日期间在大型综合医疗系统内的 17 家急诊室之一就诊的所有成年患者，这些患者被诊断为 COVID-19，并在临床检查中进行了 D-二聚体和 CTPA 检查。这项研究包括城市、郊区和农村地区的急诊室。通过计算灵敏度和特异性来评估 D-二聚体检测在区分 PE 患者和非 PE 患者方面的性能。本研究共纳入了 3133 名患者（图 1）。在3133名患者中，2846人（91%）D-二聚体异常，287人（9%）D-二聚体正常。在 D-二聚体异常组中，145 人（5%）在 CTPA 检查中出现 PE。在 D-二聚体正常组中，有 285 名患者（99.3%）在 CTPA 检查中没有出现 PE。在这一人群中，D-二聚体的敏感性为 98.6%，特异性为 9.5%。总之，我们的研究发现，D-二聚体正常或经年龄调整的 COVID-19 (+) 患者可以安全地排除 PE。

{"title":"Can a negative d-dimer rule out pulmonary embolism in patients with COVID-19?","authors":"","doi":"10.1016/j.jemrpt.2024.100100","DOIUrl":"10.1016/j.jemrpt.2024.100100","url":null,"abstract":"<div><h3>Background</h3><p>Globally, there have been more than 771 million confirmed cases of COVID-19 and more than 6.9 million deaths. The relationship between Covid-19 and pulmonary embolism (PE) has been well-established.</p></div><div><h3>Objectives</h3><p>We evaluated the correlation between normal D-dimer levels and negative findings on computed tomography pulmonary angiogram (CTPA) to assess its predictive value. Additionally, we determined the sensitivity and specificity of a D-dimer in COVID-19 (+) patients.</p></div><div><h3>Methods</h3><p>This was a retrospective cohort study of all adult patients presenting to one of 17 EDs within a large integrated healthcare system between March 1, 2020, and December 31, 2021, who were diagnosed with COVID-19 and had a D-dimer and CTPA as part of their clinical workup. This study includes EDs in urban, suburban, and rural areas. Sensitivity and specificity were calculated to assess the performance of D-dimer tests in discriminating those with and without PE. Multiple logistic regression was used to assess the effect of D-dimer test results in predicting PE.</p></div><div><h3>Results</h3><p>A total of 3133 patients were included in this study (Fig. 1). Of 3133 patients, 2846 (91 %) had an abnormal D-dimer, and 287 (9 %) had a normal D-dimer. In the group with the abnormal D-dimer, 145 (5 %) had a PE on CTPA. In the group with the normal D-dimer, 285 (99.3 %) patients did not have a PE on CTPA. The sensitivity of D-dimer in this population was 98.6 %, and the specificity was 9.5 %. Patients with abnormal D-dimer levels were 7.86 times more likely to have a PE.</p></div><div><h3>Conclusion</h3><p>In conclusion, our study found that PE could be safely excluded for COVID-19 (+) patients with a normal or age-adjusted D-dimer.</p></div>","PeriodicalId":73546,"journal":{"name":"JEM reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S2773232024000300/pdfft?md5=2ad8744c999457e51c3658c1dfac18a3&pid=1-s2.0-S2773232024000300-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141622199","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Hypercalcemia-induced pancreatitis in a women with a new diagnosis of lung cancer 一名新诊断出肺癌的妇女因高钙血症引发胰腺炎

JEM reports

Pub Date : 2024-07-06 DOI: 10.1016/j.jemrpt.2024.100101

Matthew Baniqued , Rahul Nene

Background

Hypercalcemia can present in myriad ways and has an extensive differential diagnosis. It can affect numerous different organ systems, resulting in an array of symptoms.

Report

We present the case of a 53-year-old female who presented to a rural emergency department with abdominal pain and vomiting. She was found to have a markedly elevated calcium level and an elevated lipase. Advanced imaging revealed a new lung mass. She was admitted to the hospital with a diagnosis of hypercalcemia of malignancy, with hypercalcemia-induced pancreatitis. She was treated with intravenous fluids, bisphosphonates, and calcitonin, and eventually discharged home with close follow up with an oncologist.

Why Should an Emergency Physician Be Aware of This

Hypercalcemia can result in severe end-organ damage or fatal dysrhythmia. Prompt treatment and identification of underlying pathology is essential to minimize morbidity and mortality.

背景高钙血症的表现形式多种多样，鉴别诊断范围很广。我们报告的病例是一名 53 岁的女性，她因腹痛和呕吐到农村急诊科就诊。她被发现血钙水平明显升高，脂肪酶升高。先进的影像学检查发现了一个新的肺部肿块。她入院后被诊断为恶性肿瘤高钙血症，并伴有高钙血症诱发的胰腺炎。她接受了静脉输液、双磷酸盐和降钙素治疗，最终出院回家，并接受了肿瘤科医生的密切随访。急诊医生为什么要注意这一点高钙血症可导致严重的内脏损害或致命的心律失常。为了将发病率和死亡率降至最低，及时治疗和确定潜在病理至关重要。

引用次数: 0

Letter to Editor: Treatment of post-traumatic occipital neuralgia with ultrasound-guided greater occipital nerve hydrodissection in the emergency department 致编辑的信：在急诊科使用超声引导下的大枕神经水切割术治疗外伤后枕神经痛

JEM reports

Pub Date : 2024-06-26 DOI: 10.1016/j.jemrpt.2024.100096

Gabriel Rose

引用次数: 0

Letter to the Editor – Suboccipital sonoanatomy - Sonoanatomy labelling errors and effective novel techniques of ultrasound-guided hydrodissection of the greater occipital nerve 主题致编辑的信 - 枕下超声解剖学 - 超声解剖学标记错误和有效的超声引导下大枕神经水切术

JEM reports

Pub Date : 2024-06-15 DOI: 10.1016/j.jemrpt.2024.100095

King Hei Stanley Lam

引用次数: 0

Aims and Scope 目标和范围

JEM reports

Pub Date : 2024-06-01 DOI: 10.1016/S2773-2320(24)00028-2

引用次数: 0

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