JEM reports最新文献_第8页

High dose intravenous ascorbic acid masking hypoglycemia in a patient presenting with stroke-like symptoms: A case report 高剂量静脉注射抗坏血酸掩盖出现卒中样症状患者的低血糖：1例报告

JEM reports

Pub Date : 2024-12-26 DOI: 10.1016/j.jemrpt.2024.100136

John Seaser , Brooke Sherman

Background

Point of care glucometers are commonly used in the emergency setting on patients presenting with stroke-like symptoms to rule out abnormal glucose levels as a cause. High doses of intravenous (IV) ascorbic acid have been shown to interfere with the accuracy of point of care glucose readings and some continuous glucose monitors (CGM). This interaction can cause falsely elevated point of care glucose readings which can mask true hypoglycemia.

Case report

A 65-year-old female with a past medical history of leukemia and type 1 diabetes mellitus on an insulin pump presented with stroke-like symptoms after receiving an IV infusion of high dose ascorbic acid as an adjunctive cancer treatment. Point of care glucose upon emergency department arrival was 127 mg/dL, however, serum glucose resulted as 36 mg/dL. The serum glucose was thought to be an error when a repeated point of care glucose was 128 mg/dL. The patient was considered for thrombolytic therapy, but it was ultimately held. A repeat serum glucose was again critically low at 37 mg/dL, and around this time the drug-device interaction was discovered. The patient was given IV dextrose with immediate resolution of her symptoms.

Why should an emergency physician be aware of this?

Symptoms of hypoglycemia can mimic stroke, and not recognizing hypoglycemia could result in inappropriate thrombolytic administration or delayed correction of glucose. As outpatient vitamin and hydration clinics are becoming more prevalent, providers should be aware of the drug-device interaction between IV ascorbic acid and glucose meters that could negatively impact care.

背景：急诊血糖仪通常用于出现卒中样症状的患者，以排除血糖水平异常的原因。高剂量静脉（IV）抗坏血酸已被证明会干扰点护理血糖读数和一些连续血糖监测仪（CGM）的准确性。这种相互作用会导致血糖读数错误升高，从而掩盖了真正的低血糖。病例报告：一名65岁女性，既往有白血病和1型糖尿病病史，需要胰岛素泵治疗，在接受高剂量抗坏血酸静脉输注作为辅助癌症治疗后出现卒中样症状。到达急诊科时的护理点血糖为127 mg/dL，然而，血清血糖为36 mg/dL。血清葡萄糖被认为是一个错误，当一个重复的护理点葡萄糖是128毫克/分升。患者被考虑进行溶栓治疗，但最终被搁置。重复血清葡萄糖再次低至37 mg/dL，大约在这个时候发现了药物-装置的相互作用。患者静脉注射葡萄糖后症状立即消失。急诊医生为什么要意识到这一点？低血糖的症状可以模拟中风，不认识低血糖可能导致不适当的溶栓给药或延迟血糖校正。随着门诊维生素和水合门诊越来越普遍，提供者应该意识到静脉抗坏血酸和血糖仪之间的药物装置相互作用，这可能会对护理产生负面影响。

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引用次数: 0

Procedural pain management in an academic emergency department, a pilot study 一个学术急诊科的程序性疼痛管理，一项试点研究

JEM reports

Pub Date : 2024-12-19 DOI: 10.1016/j.jemrpt.2024.100134

Irvan J. Bubic , Sidra L. Speaker , Christopher J. Coyne , Jessica C. Oswald

Background

Pain is the leading cause of Emergency Department (ED) visits and untreated acute pain can frequently transition to chronic pain. (1,2) A 2020 pilot study showed that an ED-physician-led procedural pain management program reduced pain. (3)

Objectives

Our objective was to determine the feasibility and usefulness of a Mobile ED (MED) Pain Management program led by a dual-trained Pain Management and Emergency physician.

Methods

We included adult patients who visited the ED at a large academic hospital between October 26th and November 17th, 2020. Patients had a variety of types of pain and were treated with bedside nerve blocks. We recorded procedure indication, demographic data, and pre-and-post Visual Analog Scale (VAS) pain scores. We also captured patient and provider satisfaction, and billing data.

Results

The MED team was available for a total of 30 h and performed 14 procedures on 12 patients and 4 consults without procedures on 4 additional patients. VAS 30-min score reductions ranged from 20 % (intercostal nerve blocks) to 100 % erector spinae plane block (ESPB). The average VAS pain reduction was 58 %. The most common procedure performed was the ESPB with mean VAS pain reduction of 74 %. The procedures and consults produced 50.13 RVUs total and work Relative Value Units (wRVUs) of 29.4. Average RVU was 3.13 (1.84 wRVU) per patient and 1.67 RVU (0.98 wRVU) per hour.

Conclusions

These preliminary data suggest that although implementation of a dedicated ED pain could potentially lead to improved pain relief, it may not be financially feasible in this setting.

背景：疼痛是急诊科（ED）就诊的主要原因，未经治疗的急性疼痛经常会转变为慢性疼痛。（1,2） 2020年的一项试点研究表明，ed医生主导的程序性疼痛管理计划可以减少疼痛。(3)目的我们的目的是确定由受过双重训练的疼痛管理和急诊医生领导的移动ED （MED）疼痛管理项目的可行性和有效性。方法纳入2020年10月26日至11月17日在某大型学术医院急诊科就诊的成年患者。患者有各种类型的疼痛，采用床边神经阻滞治疗。我们记录手术指征、人口统计数据和视觉模拟评分（VAS）前后疼痛评分。我们还捕获了患者和提供者满意度以及账单数据。结果MED团队共工作30 h，对12例患者进行了14次手术，对另外4例患者进行了4次无手术会诊。VAS 30分钟评分降低范围从20%（肋间神经阻滞）到100%竖脊肌平面阻滞（ESPB）。VAS疼痛平均减轻58%。最常见的手术是ESPB，平均VAS疼痛减轻74%。程序和咨询共产生50.13 rvu，工作相对价值单位（wrvu）为29.4。平均RVU为3.13 (1.84 wRVU) /例，1.67 RVU (0.98 wRVU) /小时。这些初步数据表明，尽管实施专门的ED疼痛可能会改善疼痛缓解，但在这种情况下，它可能在经济上不可行。

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引用次数: 0

Lemierre's syndrome diagnosed using bedside ultrasound in the emergency department 在急诊科使用床边超声诊断莱米尔综合征

JEM reports

Pub Date : 2024-12-19 DOI: 10.1016/j.jemrpt.2024.100135

Anis Adnani , Wesley Eilbert

Background

Lemierre's syndrome (LS) is a rare disease, typically occurring after a recent oropharyngeal infection. It is characterized by septic thrombophlebitis of the internal jugular (IJ) vein and bacteremia with metastatic septic emboli. Computed tomography (CT) of the neck with intravenous contrast is the imaging study of choice to diagnose the IJ vein thrombosis present with LS.

Case report

We present the case of an 18-year-old male who presented to the emergency department (ED) with right sided neck pain and shortness of breath. He had been seen in the ED two days earlier complaining of sore throat and was diagnosed with a viral infection. CT examinations of the neck and chest with intravenous contrast found multifocal bilateral nodular pulmonary densities with some soft tissue stranding adjacent to the right carotid sheath. No intraluminal filling defects of the right IJ vein were noted. A bedside ultrasound revealed a non-compressible hyperechoic thrombus in the right IJ vein, confirming the diagnosis of LS. To our knowledge, this is only the second reported case of LS diagnosed using bedside ultrasound that was initially missed on CT.

Why should an emergency physician be aware of this? Rapid recognition of LS, a potentially fatal illness, is paramount to optimize outcome. Bedside ultrasound is a useful tool available to emergency physicians to diagnose this disease and initiate prompt treatment.

lemierre综合征（LS）是一种罕见的疾病，通常发生在近期口咽感染后。它的特点是脓毒性血栓性静脉炎的颈内静脉（IJ）和菌血症转移脓毒性栓塞。颈部计算机断层扫描（CT）静脉造影剂是诊断LS患者IJ静脉血栓形成的首选影像学研究。病例报告我们提出的情况下，18岁的男性谁提出了急诊科（ED）右侧颈部疼痛和呼吸短促。两天前，他在急诊科抱怨喉咙痛，并被诊断为病毒感染。颈部及胸部CT检查及静脉造影发现双侧多灶性肺结节密度伴一些软组织搁浅于右侧颈动脉鞘附近。未见右侧IJ静脉腔内充盈缺损。床边超声显示右侧IJ静脉出现不可压缩的高回声血栓，确认LS的诊断。据我们所知，这是第二例使用床边超声诊断的LS病例，最初在CT上被遗漏。急诊医生为什么要意识到这一点？LS是一种潜在的致命疾病，快速识别对于优化结果至关重要。床边超声是一种有用的工具，可用于急诊医生诊断这种疾病，并开始及时治疗。

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引用次数: 0

A case report: Point-of-care ultrasound revealing cystolithiasis in a bladder diverticulum as the cause of sepsis and encephalopathy 病例报告：点护理超声显示膀胱憩室膀胱结石作为败血症和脑病的原因

JEM reports

Pub Date : 2024-12-12 DOI: 10.1016/j.jemrpt.2024.100133

Kahra Nix , Alexandra Parson , Nicholas DiMeo , Jeffery Baker

引用次数: 0

Waiting room zero until noon: An emergency department quality improvement initiative with downstream effects 中午前零号候诊室：一项具有下游效应的急诊科质量改进倡议

JEM reports

Pub Date : 2024-12-08 DOI: 10.1016/j.jemrpt.2024.100131

Alice Kidder Bukhman , Joshua W. Joseph , Chandler R. Bianchi , Paul C. Chen , Da’Marcus Eugene Baymon , Robin Powell , Beth Waters , Patrick Hollowell , Leon Dahomey Sanchez

Background

Rising ED boarding and visit volumes are challenges to maintaining patient flow and avoiding patients leaving without being seen.

Objectives

We aimed to decrease left without being seen and improve ED patient flow by minimizing time patients spent in the waiting room in the early hours of the day when treatment spaces are usually available.

Methods

We implemented a “Waiting room zero before noon” campaign in our urban community emergency department. Providers and nurses were messaged about this goal and the expectation was set that patients should be brought to a room even if a nurse was not immediately available to care for them.

Results

In the three months following this campaign, we experienced a significant decrease in left without being seen. This decrease persisted over the subsequent two years, despite increasing patient volume.

Conclusion

A simple, cost-neutral campaign aimed at changing workflow culture was able to achieve improvements in patient flow despite continued challenges of rising boarding and volume.

背景：急诊科登诊量和诊断量的增加对维持病人流量和避免病人在没有看到的情况下离开是一个挑战。我们的目标是通过减少患者在治疗空间通常可用的凌晨等候室花费的时间来减少未被看到的情况，并改善急诊科患者的流量。方法在我市社区急诊科开展“中午前无候诊室”活动。提供者和护士被告知这一目标，并设定了这样的期望：即使护士不能立即照顾他们，也应该把病人带到一个房间。结果在这次活动后的三个月里，我们经历了明显的消失。在随后的两年中，尽管患者数量增加，但这种下降仍在持续。结论：一项旨在改变工作流程文化的简单、成本中立的活动能够改善患者流程，尽管患者上岗率和数量持续上升。

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引用次数: 0

Implementing artificial intelligence for electrocardiogram interpretation: A case study 在心电图判读中应用人工智能：一个案例研究

JEM reports

Pub Date : 2024-12-07 DOI: 10.1016/j.jemrpt.2024.100132

Jace C. Bradshaw , Emily Nagourney , McKenzie Warshel , P Logan Weygandt

Background

Artificial intelligence (AI) is expected to have a growing role in medical diagnostic interpretation and existing programs should be challenged with difficult cases in clinical practice senerios. An isolated posterior myocardial infarction (MI) is suggested by ST segment depression in the anteroseptal leads on a standard 12-lead electrocardiogram (ECG) and confirmed by the presence of 0.5mm ST segment elevation in any of the posterior leads (V7-V9). Isolated posterior MI is rare (potentially <4 % of all MIs).

Case report

We present a case of a 79-year-old man who presented with intermittent chest pain and subtle ECG changes concerning for a posterior MI. His catheterization images confirm a completely occluded LCx artery. We also present the AI analysis of the ECG's crucial for making the diagnosis in this case.

Why should an Emergency Physician be aware of this?

Given the diagnostic challenge of posterior wall MIs with a standard 12-lead ECG, clinical suspicion for a posterior MI should remain high with any degree of ST segment depression in the anterior leads and prompt the emergency physician to obtain a posterior ECG. AI-based ECG interpretation was able to determine that this patient was having an occlusive myocardial infarction. We discuss how to utilize the third-party AI for diagnostic aid.

人工智能（AI）有望在医学诊断解释中发挥越来越大的作用，现有的程序应该受到临床实践中疑难病例的挑战。在标准的12导联心电图（ECG）上，室间隔导联ST段下降提示孤立性后路心肌梗死（MI），并通过任何后路导联（V7-V9）出现0.5mm ST段升高证实。孤立的后路心肌梗死是罕见的（可能占所有心肌梗死的4%）。病例报告：我们报告一例79岁的男性患者，其表现为间歇性胸痛和轻微的ECG变化，与后部心肌梗死有关。他的导管造影图像证实LCx动脉完全闭塞。我们还介绍了人工智能分析的心电图的关键作出诊断，在这种情况下。为什么急诊医生应该意识到这一点？考虑到用标准12导联心电图诊断后壁心肌梗死的挑战，临床对后壁心肌梗死的怀疑应该保持在高水平，因为前导联有任何程度的ST段下降，并促使急诊医生获得后壁心电图。基于人工智能的心电图解释能够确定该患者患有闭塞性心肌梗死。我们讨论了如何利用第三方人工智能进行诊断辅助。

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引用次数: 0

A rare case of yellow nail syndrome in the emergency room setting: A case report 急诊室中罕见的黄指甲综合征1例：1例报告

JEM reports

Pub Date : 2024-11-30 DOI: 10.1016/j.jemrpt.2024.100130

Jordan S. Elmowitz , Michael E. Nelson

Background

Yellow nail syndrome (YNS) is a rare condition that consists of the following triad: yellowing of the nails, lymphedema, and pulmonary disease. The disease may be difficult to diagnose as all three components of the triad may not be present simultaneously, and on initial evaluation, it can mimic common conditions such as onychomycosis, psoriasis, and lichen planus. This is a case of yellow nail syndrome in the emergency department.

Case report

This is a case of a 31-year-old male who presented to the emergency room with a chief complaint of bilateral lower extremity swelling, yellow discoloration of his fingernails, and productive cough.

Why should an emergency physician be aware of this?

Recognition of the constellation of findings can avoid unnecessary testing, exposure to potentially harmful inappropriate medications, and provide psychologic relief to the patient. Subsequently, this may reduce patient cost, avoid unnecessary side effects, and lead to appropriate disease management.

背景：黄指甲综合征（YNS）是一种罕见的疾病，由以下三种症状组成：指甲变黄、淋巴水肿和肺部疾病。这种疾病可能难以诊断，因为三联征的所有三个组成部分可能不会同时出现，并且在最初的评估中，它可以模拟常见的情况，如甲真菌病、牛皮癣和扁平苔藓。这是一个在急诊科的黄指甲综合征病例。病例报告：这是一例31岁男性患者，主诉为双侧下肢肿胀、指甲变黄和咳嗽。急诊医生为什么要意识到这一点？认识到这些发现可以避免不必要的检查，暴露于潜在有害的不适当药物，并为患者提供心理缓解。随后，这可能会降低患者的成本，避免不必要的副作用，并导致适当的疾病管理。

引用次数: 0

Spontaneous perinephric hematoma in an emergency department patient with flank pain: A case report 急诊科一名侧腹疼痛患者的自发性肾周血肿：病例报告

JEM reports

Pub Date : 2024-11-20 DOI: 10.1016/j.jemrpt.2024.100127

Amna Nawaz , Denise Elizondo , Rebecca G. Theophanous

Background

Perinephric hematomas are defined by hemorrhage originating from the kidney parenchyma into the subcapsular and perirenal spaces. Spontaneous perinephric hematomas are rare and usually occur due to an underlying renal mass, vascular abnormality, coagulation disorder, or inflammatory disorder. The classic clinical presentation includes acute flank pain, hemorrhagic shock, and detection of a renal mass. Diagnosis is by computed tomography (CT), ultrasound, or angiography.

Case report

A 74-year-old male with coronary artery disease, severe heart failure, and atrial fibrillation/flutter on apixaban presented to the emergency department (ED) with left-sided abdominal and back pain for two weeks. He denied urinary symptoms, fever, or vomiting. The patient was hypotensive with low hemoglobin (8.9g/dL), thus he received blood transfusions and apixaban reversal for hemorrhagic shock. CT scan diagnosed a 10x9 cm perinephric hematoma, and he was transferred to our hospital’s ED. Point-of-care ultrasound demonstrated a left perinephric hematoma and clotted blood in the splenorenal recess. Urology and interventional radiology (IR) were consulted, with emergent transport to IR for angiogram and left coil embolization then intensive care unit admission.

Why should an emergency medicine physician be aware of this

This case describes important diagnostic testing and bedside ultrasound utility in expediting care for patients with renal pathology. It describes a case of spontaneous renal hemorrhage and management steps including IR embolization, urology involvement, and evaluation for surgical intervention. Finally, we emphasize potential serious complications including chronic renal failure, pyelonephritis, renal obstruction, and permanent kidney distortion if disease is not recognized and treated early.

背景肾周围血肿是指从肾实质向肾囊下和肾周间隙的出血。自发性肾周围血肿非常罕见，通常是由于潜在的肾肿块、血管异常、凝血障碍或炎症性疾病引起的。典型的临床表现包括急性侧腹疼痛、失血性休克和发现肾肿块。病例报告一名 74 岁的男性患者因左侧腹部和背部疼痛两周而到急诊科就诊，他患有冠状动脉疾病、严重心力衰竭和心房颤动/扑动，正在服用阿哌沙班。他否认有泌尿系统症状、发烧或呕吐。患者血压低，血红蛋白低（8.9g/dL），因此接受了输血和阿哌沙班治疗失血性休克的逆转治疗。CT 扫描诊断为 10x9 厘米肾周血肿，患者被转至我院急诊科。床旁超声检查显示左肾周围血肿，脾肾凹陷处有凝血。泌尿外科和介入放射科（IR）会诊后，紧急送往介入放射科进行血管造影和左侧线圈栓塞术，然后送入重症监护室。急诊科医生为什么要注意这个病例这个病例描述了重要的诊断测试和床旁超声在加快肾脏病变患者治疗方面的作用。它描述了一例自发性肾出血和处理步骤，包括红外栓塞、泌尿科介入和手术干预评估。最后，我们强调了潜在的严重并发症，包括慢性肾功能衰竭、肾盂肾炎、肾梗阻，以及如果不及早发现和治疗，将导致永久性肾变形。

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引用次数: 0

Symptomatic complete heart block: A rare complication of anterior myocardial infarction in a young, fit male: A case report 症状性完全性心脏传导阻滞：体格健壮的年轻男性前心肌梗死的罕见并发症：病例报告

JEM reports

Pub Date : 2024-11-19 DOI: 10.1016/j.jemrpt.2024.100129

Huang Huiling , Lee Keyao , Zhang Yuan Helen

Background

Acute myocardial infarction (AMI) is a major cause of morbidity and mortality, typically affecting older individuals with multiple cardiovascular comorbidities. Complete heart block (CHB) is a rare but serious complication of AMI, requiring prompt intervention. We present a case of AMI involving total occlusion of the proximal left anterior descending (LAD) coronary artery, leading to CHB and alternating bundle branch blocks, requiring temporary pacing. The patient was discharged with good outcomes.

Case report

A 41-year-old Indian male with no significant past medical history presented with chest discomfort and abnormal electrocardiogram (ECG) findings. Emergency percutaneous coronary intervention (PCI) revealed critical proximal LAD occlusion and moderate disease in the other coronary arteries. The patient developed trifascicular block and subsequent episodes of alternating right and left bundle branch block, necessitating temporary pacing. Despite the complex arrhythmias resulting from his anterior AMI and the transient need for a temporary pacing wire, the patient showed remarkable improvement post-revascularization, with no requirement for a permanent pacemaker at discharge.

Why should an Emergency Physician be aware of this?

This case highlights that CHB can occur with anterior, not just inferior MI. When associated with anterior MI, there is extensive myocardial injury and a high risk of conduction abnormalities, which can potentially be permanent. While AMI can cause a range of complications, CHB tends to be rarer in LAD occlusion based on the anatomy it supplies. Recognizing and promptly treating both the primary lesion and its complications especially in the younger patients, can improve outcomes.

背景急性心肌梗死（AMI）是发病和死亡的主要原因，通常影响患有多种心血管并发症的老年人。完全性心脏传导阻滞（CHB）是急性心肌梗死罕见但严重的并发症，需要及时干预。我们介绍了一例急性心肌梗死病例，患者左前降支（LAD）冠状动脉近端完全闭塞，导致完全性心脏传导阻滞和交替性束支传导阻滞，需要临时起搏。病例报告一名 41 岁的印度男性因胸部不适和异常心电图（ECG）发现而就诊，既往无明显病史。急诊经皮冠状动脉介入治疗（PCI）发现左上臂近端严重闭塞，其他冠状动脉中度病变。患者出现了三束支传导阻滞，随后又出现了左右束支交替传导阻滞，不得不进行临时起搏。尽管前部急性心肌梗死导致复杂的心律失常，而且需要使用临时起搏导线，但患者在血管重建后病情明显好转，出院时无需使用永久起搏器。如果伴有前心肌梗死，则会造成广泛的心肌损伤，并极有可能出现永久性传导异常。虽然急性心肌梗死可导致一系列并发症，但基于其所提供的解剖结构，CHB 在 LAD 闭塞中往往较为罕见。识别并及时治疗原发病变及其并发症，尤其是年轻患者，可以改善预后。

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引用次数: 0

Case of monocular visual impairment 单眼视力障碍病例

JEM reports

Pub Date : 2024-11-17 DOI: 10.1016/j.jemrpt.2024.100128

Lev Libet, Edward McCrink, Lawrence Liu

引用次数: 0