{"title":"Cerebral air embolism after flushing a radial arterial line: a case report","authors":"M. Zink, Gilbert Hainzl, A. Maier, V. Stadlbauer","doi":"10.21037/JECCM-20-174","DOIUrl":"https://doi.org/10.21037/JECCM-20-174","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-04-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48133437","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-04-01Epub Date: 2021-04-25DOI: 10.21037/jeccm-20-154
Ronald K Akiki, Rajsavi S Anand, Mimi Borrelli, Indra Neil Sarkar, Paul Y Liu, Elizabeth S Chen
Background: Open wounds have a significant impact on the health of patients causing pain, loss of function, and death. Labeled as a comorbid condition, open wounds represent a "silent epidemic" that affect a large portion of the US population. Due to their burden of care, open wound patients face an increased risk of ICU stay and mortality. There is a dearth of studies that investigate mortality among wound patients in the ICU. We sought to develop a model that predicts the risk of mortality among wound patients in the ICU.
Methods: Random forest and binomial logistic regression models were developed to predict the risk of mortality among open wound patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. MIMIC-III includes de-identified data for patients who stayed in critical care units of the Beth Israel Deaconess Medical Center between 2001 and 2012. Six variables were used to develop the model (wound location, gender, age, admission type, minimum platelet count and hyperphosphatemia). The Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index were used to assess model strength.
Results: A total of 3,937 patients were included with a mean age of 76.57. Of those, 3,372 (85%) survived and 565 (15%) died during their ICU stay. The random forest model achieved an area under the curve (AUC) of 0.924. The CCI and Elixhauser models resulted in AUC of 0.528 and 0.565, respectively.
Conclusions: Machine learning models may allow clinicians to provide better care and management to open wound patients in the ICU.
{"title":"Predicting open wound mortality in the ICU using machine learning.","authors":"Ronald K Akiki, Rajsavi S Anand, Mimi Borrelli, Indra Neil Sarkar, Paul Y Liu, Elizabeth S Chen","doi":"10.21037/jeccm-20-154","DOIUrl":"https://doi.org/10.21037/jeccm-20-154","url":null,"abstract":"<p><strong>Background: </strong>Open wounds have a significant impact on the health of patients causing pain, loss of function, and death. Labeled as a comorbid condition, open wounds represent a \"silent epidemic\" that affect a large portion of the US population. Due to their burden of care, open wound patients face an increased risk of ICU stay and mortality. There is a dearth of studies that investigate mortality among wound patients in the ICU. We sought to develop a model that predicts the risk of mortality among wound patients in the ICU.</p><p><strong>Methods: </strong>Random forest and binomial logistic regression models were developed to predict the risk of mortality among open wound patients in the Medical Information Mart for Intensive Care III (MIMIC-III) database. MIMIC-III includes de-identified data for patients who stayed in critical care units of the Beth Israel Deaconess Medical Center between 2001 and 2012. Six variables were used to develop the model (wound location, gender, age, admission type, minimum platelet count and hyperphosphatemia). The Charlson Comorbidity Index (CCI) and Elixhauser Comorbidity Index were used to assess model strength.</p><p><strong>Results: </strong>A total of 3,937 patients were included with a mean age of 76.57. Of those, 3,372 (85%) survived and 565 (15%) died during their ICU stay. The random forest model achieved an area under the curve (AUC) of 0.924. The CCI and Elixhauser models resulted in AUC of 0.528 and 0.565, respectively.</p><p><strong>Conclusions: </strong>Machine learning models may allow clinicians to provide better care and management to open wound patients in the ICU.</p>","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":"5 ","pages":"13"},"PeriodicalIF":0.0,"publicationDate":"2021-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/e2/1b/nihms-1732035.PMC8579960.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39702220","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}
: Abdominal pain is one of the most common complaints seen in the pediatric emergency department (PED). Because of the broad range of potential diagnoses, it can pose challenges in the diagnostic evaluation and treatment in the young child. A 3-year-old previously healthy girl presented to our PED with abdominal pain, abdominal distention, poor appetite, and recent weight gain. Physical examination was notable for a significantly distended taut abdomen in an otherwise well appearing child with normal vital signs. Initial evaluation yielded anemia, elevated inflammatory markers, and an abdominal ultrasound (US) showing a large amount of complex intra-abdominal ascites without definite intra-peritoneal mass. Pediatric surgery, pediatric gastroenterology, and pediatric oncology were consulted. A magnetic resonance imaging (MRI) of the abdomen was performed and revealed a large amount of intraperitoneal fluid with a component of internal complexity and no suspicious enhancement to suggest overt malignant process. She was ultimately diagnosed with a large congenital omental cyst that required resection and omentectomy. Pathology was consistent with a macrocystic lymphatic malformation. Lymphatic malformations are uncommon pediatric lesions, accounting for only 5% of benign tumors in childhood. Common locations include the neck, axillae, and rarely involve the gastrointestinal tract. Clinical presentation varies depending on the size and location of the tumor. Many present later in life due to their diagnostic challenges.
{"title":"An unusual cause of a toddler with a big belly, abdominal lymphatic malformation case report","authors":"Lauren C. Riney","doi":"10.21037/JECCM-20-146","DOIUrl":"https://doi.org/10.21037/JECCM-20-146","url":null,"abstract":": Abdominal pain is one of the most common complaints seen in the pediatric emergency department (PED). Because of the broad range of potential diagnoses, it can pose challenges in the diagnostic evaluation and treatment in the young child. A 3-year-old previously healthy girl presented to our PED with abdominal pain, abdominal distention, poor appetite, and recent weight gain. Physical examination was notable for a significantly distended taut abdomen in an otherwise well appearing child with normal vital signs. Initial evaluation yielded anemia, elevated inflammatory markers, and an abdominal ultrasound (US) showing a large amount of complex intra-abdominal ascites without definite intra-peritoneal mass. Pediatric surgery, pediatric gastroenterology, and pediatric oncology were consulted. A magnetic resonance imaging (MRI) of the abdomen was performed and revealed a large amount of intraperitoneal fluid with a component of internal complexity and no suspicious enhancement to suggest overt malignant process. She was ultimately diagnosed with a large congenital omental cyst that required resection and omentectomy. Pathology was consistent with a macrocystic lymphatic malformation. Lymphatic malformations are uncommon pediatric lesions, accounting for only 5% of benign tumors in childhood. Common locations include the neck, axillae, and rarely involve the gastrointestinal tract. Clinical presentation varies depending on the size and location of the tumor. Many present later in life due to their diagnostic challenges.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42903257","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Koral Shah, H. Ahmad, Jonathan E. Wilson, Mukesh Goyal, S. Dubin
Penetrating ulcers of the aorta, aortic dissections, and intramural hematomas (IMH) all fall under acute aortic syndromes (AAS) and have important similarities and differences. We present a case of an asymptomatic patient with uncontrolled hypertension who was found to have a unique combination of penetrating aortic ulcers (PAUs) with an associated IMH. Furthermore, the patient had PAUs located in the aortic arch, which is an uncommon since the majority are located in the descending thoracic aorta. His PAUs and IMH progressed despite medical management and subsequently required thoracic endovascular aortic repair (TEVAR). The treatment of IMHs and PAUs is less well known compared to the classic aortic dissection. Often, they may not be treated as an AAS or may be treated as an aortic dissection. This case report addresses this challenge clinicians face with unclear delineation of treatment between different AAS. This case demonstrates how a type B IMH, when associated with penetrating ulcers, may follow a more malignant course, and should be considered for early surgical intervention. This case illustrates the importance of understanding the distinction between the AAS and how treatment differs based on Stanford classification and risk factors of progression.
{"title":"Progression of aortic intramural hematoma with associated penetrating aortic ulcers with medical management requiring surgical management case report","authors":"Koral Shah, H. Ahmad, Jonathan E. Wilson, Mukesh Goyal, S. Dubin","doi":"10.21037/JECCM-20-153","DOIUrl":"https://doi.org/10.21037/JECCM-20-153","url":null,"abstract":"Penetrating ulcers of the aorta, aortic dissections, and intramural hematomas (IMH) all fall under acute aortic syndromes (AAS) and have important similarities and differences. We present a case of an asymptomatic patient with uncontrolled hypertension who was found to have a unique combination of penetrating aortic ulcers (PAUs) with an associated IMH. Furthermore, the patient had PAUs located in the aortic arch, which is an uncommon since the majority are located in the descending thoracic aorta. His PAUs and IMH progressed despite medical management and subsequently required thoracic endovascular aortic repair (TEVAR). The treatment of IMHs and PAUs is less well known compared to the classic aortic dissection. Often, they may not be treated as an AAS or may be treated as an aortic dissection. This case report addresses this challenge clinicians face with unclear delineation of treatment between different AAS. This case demonstrates how a type B IMH, when associated with penetrating ulcers, may follow a more malignant course, and should be considered for early surgical intervention. This case illustrates the importance of understanding the distinction between the AAS and how treatment differs based on Stanford classification and risk factors of progression.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-03-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42222191","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-01-01Epub Date: 2021-01-25DOI: 10.21037/jeccm-20-92
Erin M Wilfong, Christine M Lovly, Erin A Gillaspie, Li-Ching Huang, Yu Shyr, Jonathan D Casey, Brian I Rini, Matthew W Semler
Background: The COVID-19 pandemic has overwhelmed hospital systems in multiple countries and necessitated caring for patients in atypical healthcare settings. The goal of this study was to ascertain if the conventional critical care severity scores qSOFA, SOFA, APACHE-II, and SAPS-II could predict which patients admitted to the hospital from an emergency department would eventually require intensive care. Methods: This single-center, retrospective cohort study enrolled patients admitted to Vanderbilt University Hospital from the emergency room with symptomatic, confirmed COVID-19 infection between March 8, 2020 through May 15, 2020. Clinical phenotyping was performed by chart abstraction, and the correlation of the qSOFA, SOFA, APACHE-II, and SAPS-II scores for the primary endpoint of ICU admission and secondary endpoint of in-hospital mortality was evaluated. Results: During the study period, 128 patients were admitted to Vanderbilt University Hospital from the emergency room with COVID-19. Of these, 39 patients eventually required intensive care; the remaining 89 were discharged from the medical ward. All severity of illness scores demonstrated at least moderate ability to identify patients who would die or require ICU admission. Of the three severity of illness scores assessed, the APACHE-II score performed best with an AUC of 0.851 (95% CI: 0.786 to 0.917) for identifying patient that would require ICU admission. No patient with an APACHE-II score at the time of presentation less than 8 or qSOFA of 0 required intensive care unit (ICU) admission. All patients with an APACHE-II score less than 10 or qSOFA score of 0 survived to hospital discharge. Conclusions: The APACHE-II score accurately predicts the eventual need for ICU admission. This may allow for risk-stratification of patients safe to treat in alternative health care settings and prognostic enrichment to accelerate clinical trials of COVID-19 therapies.
{"title":"Severity of illness scores at presentation predict ICU admission and mortality in COVID-19.","authors":"Erin M Wilfong, Christine M Lovly, Erin A Gillaspie, Li-Ching Huang, Yu Shyr, Jonathan D Casey, Brian I Rini, Matthew W Semler","doi":"10.21037/jeccm-20-92","DOIUrl":"https://doi.org/10.21037/jeccm-20-92","url":null,"abstract":"Background: The COVID-19 pandemic has overwhelmed hospital systems in multiple countries and necessitated caring for patients in atypical healthcare settings. The goal of this study was to ascertain if the conventional critical care severity scores qSOFA, SOFA, APACHE-II, and SAPS-II could predict which patients admitted to the hospital from an emergency department would eventually require intensive care. Methods: This single-center, retrospective cohort study enrolled patients admitted to Vanderbilt University Hospital from the emergency room with symptomatic, confirmed COVID-19 infection between March 8, 2020 through May 15, 2020. Clinical phenotyping was performed by chart abstraction, and the correlation of the qSOFA, SOFA, APACHE-II, and SAPS-II scores for the primary endpoint of ICU admission and secondary endpoint of in-hospital mortality was evaluated. Results: During the study period, 128 patients were admitted to Vanderbilt University Hospital from the emergency room with COVID-19. Of these, 39 patients eventually required intensive care; the remaining 89 were discharged from the medical ward. All severity of illness scores demonstrated at least moderate ability to identify patients who would die or require ICU admission. Of the three severity of illness scores assessed, the APACHE-II score performed best with an AUC of 0.851 (95% CI: 0.786 to 0.917) for identifying patient that would require ICU admission. No patient with an APACHE-II score at the time of presentation less than 8 or qSOFA of 0 required intensive care unit (ICU) admission. All patients with an APACHE-II score less than 10 or qSOFA score of 0 survived to hospital discharge. Conclusions: The APACHE-II score accurately predicts the eventual need for ICU admission. This may allow for risk-stratification of patients safe to treat in alternative health care settings and prognostic enrichment to accelerate clinical trials of COVID-19 therapies.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":"5 ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/37/3f/nihms-1697398.PMC8232354.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39115373","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}
Jevaughn S Davis, Omowunmi Adedeji, K. Hawkins, Riad Akkari, M. Seneff
: A 55-year-old woman with no significant past medical history presented with concerns of a retropharyngeal abscess (RPA) associated with bilateral internal jugular vein (IJV) thromboses. Computed tomography (CT) demonstrated the RPA, in addition to bilateral IJV thrombosis and ground-glass opacities in the lungs suggestive of Lemierre syndrome. This rare syndrome begins as an oropharyngeal infection and frequently involves inflammation within the vein wall, infected thrombus, surrounding soft tissue inflammation, persistent bacteremia, and septic emboli. Diagnosis is purely clinical; prompt and timely identification and treatment of Lemierre Syndrome decreases mortality by a factor of 4. Standard treatment is tailored antibiotic administration, though other therapies such as anticoagulation and interventional procedures such as thrombectomy remain controversial and debated. The available literature does not elucidate a role for thrombectomy. We present a patient who did not improve with antibiotics and systemic anticoagulation and it was not until IJV thrombectomy that the patient demonstrated clinical improvement. From our literature review, there are no current case reports published where thrombectomy was used in the treatment of Lemierre. However, there are a few published articles that suggest some benefit to patients with treatment resistant Lemierre, given extrapolated data from thrombectomy used in the treatment of septic thrombophlebitis of the extremities. With the advancement of medical technology, new interventional methodologies should be adopted to treat this disease.
{"title":"Lemierre’s syndrome: a role for thrombectomy, a case report","authors":"Jevaughn S Davis, Omowunmi Adedeji, K. Hawkins, Riad Akkari, M. Seneff","doi":"10.21037/jeccm-21-38","DOIUrl":"https://doi.org/10.21037/jeccm-21-38","url":null,"abstract":": A 55-year-old woman with no significant past medical history presented with concerns of a retropharyngeal abscess (RPA) associated with bilateral internal jugular vein (IJV) thromboses. Computed tomography (CT) demonstrated the RPA, in addition to bilateral IJV thrombosis and ground-glass opacities in the lungs suggestive of Lemierre syndrome. This rare syndrome begins as an oropharyngeal infection and frequently involves inflammation within the vein wall, infected thrombus, surrounding soft tissue inflammation, persistent bacteremia, and septic emboli. Diagnosis is purely clinical; prompt and timely identification and treatment of Lemierre Syndrome decreases mortality by a factor of 4. Standard treatment is tailored antibiotic administration, though other therapies such as anticoagulation and interventional procedures such as thrombectomy remain controversial and debated. The available literature does not elucidate a role for thrombectomy. We present a patient who did not improve with antibiotics and systemic anticoagulation and it was not until IJV thrombectomy that the patient demonstrated clinical improvement. From our literature review, there are no current case reports published where thrombectomy was used in the treatment of Lemierre. However, there are a few published articles that suggest some benefit to patients with treatment resistant Lemierre, given extrapolated data from thrombectomy used in the treatment of septic thrombophlebitis of the extremities. With the advancement of medical technology, new interventional methodologies should be adopted to treat this disease.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41405671","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: Pulmonary emboli have varied clinical presentations and are largely determined by the size and position of these emboli. Symptoms include no symptoms at all, dyspnea, cough, or chest pain. Patients often also exhibit tachypnea and tachycardia. In more extreme cases, larger pulmonary emboli at the bifurcation of the pulmonary arteries called saddle emboli can lead to severe right heart failure and even death. Diagnosing emboli can be difficult because the constellation of symptoms discussed can also be attributed to other medical conditions like pneumothoraxes and pericarditis. For clinicians, it is paramount that prompt and accurate diagnosis of pulmonary emboli be done to facilitate expedient treatment for this condition. The Wells’ Criteria is a useful tool to stratify the risk that a patient has a pulmonary embolism. However, often patients can present with pulmonary emboli without the “typical” risk factors such as prolonged immobilization, surgery in the previous four weeks, hypercoagulable conditions, or asymmetric lower extremity swelling. We present a 66 years old African American male who arrived to the emergency department in shock and with initial electrocardiographic findings consistent with left main stenosis but catheterization findings consistent with negative coronary artery disease and was later found to have extensive bilateral pulmonary emboli.
{"title":"Obstructive shock presenting like STEMI: case report","authors":"Srikar Reddy, Xinyu von Buttlar, D. Casey","doi":"10.21037/JECCM-20-139","DOIUrl":"https://doi.org/10.21037/JECCM-20-139","url":null,"abstract":": Pulmonary emboli have varied clinical presentations and are largely determined by the size and position of these emboli. Symptoms include no symptoms at all, dyspnea, cough, or chest pain. Patients often also exhibit tachypnea and tachycardia. In more extreme cases, larger pulmonary emboli at the bifurcation of the pulmonary arteries called saddle emboli can lead to severe right heart failure and even death. Diagnosing emboli can be difficult because the constellation of symptoms discussed can also be attributed to other medical conditions like pneumothoraxes and pericarditis. For clinicians, it is paramount that prompt and accurate diagnosis of pulmonary emboli be done to facilitate expedient treatment for this condition. The Wells’ Criteria is a useful tool to stratify the risk that a patient has a pulmonary embolism. However, often patients can present with pulmonary emboli without the “typical” risk factors such as prolonged immobilization, surgery in the previous four weeks, hypercoagulable conditions, or asymmetric lower extremity swelling. We present a 66 years old African American male who arrived to the emergency department in shock and with initial electrocardiographic findings consistent with left main stenosis but catheterization findings consistent with negative coronary artery disease and was later found to have extensive bilateral pulmonary emboli.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68337524","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：