Journal of the American College of Emergency Physicians open最新文献

In patients with out-of-hospital cardiac arrest (OHCA) who attain return of spontaneous circulation (ROSC), rearrest while in the prehospital setting represents a significant barrier to survival. To date, there are limited data to guide prehospital emergency medical services (EMS) management immediately following successful resuscitation resulting in ROSC and prior to handoff in the emergency department. Post-ROSC care encompasses a multifaceted approach including hemodynamic optimization, airway management, oxygenation, and ventilation. We sought to develop an evidenced-based, goal-directed bundle of care targeting specified vital parameters in the immediate post-ROSC period, with the goal of decreasing the incidence of rearrest and improving survival outcomes. Here, we describe the rationale and development of this goal-directed bundle of care, which will be adopted by several EMS agencies within California. We convened a group of EMS experts, including EMS Medical Directors, quality improvement officers, data managers, educators, EMS clinicians, emergency medicine clinicians, and resuscitation researchers to develop a goal-directed bundle of care to be applied in the field during the period immediately following ROSC. This care bundle includes guidance for prehospital personnel on recognition of impending rearrest, hemodynamic optimization, ventilatory strategies, airway management, and diagnosis of underlying causes prior to the initiation of transport.

A 16-year-old female, with a history of spontaneous abortion 2 years ago, presented to the emergency department immediately after tissue expulsion vaginally (Figure 1). The patient had been placed on a high-dose depot of medroxyprogesterone acetate (DMPA) 4 weeks prior to presentation. Additionally, she had abdominal cramping and denied recent sexual activity, fever, or vaginal discharge. Her vital signs were normal. Complete Blood Count (CBC) and Comprehensive metabolic panel (CMP) were normal and serum human chorionic gonadotropin was <1 MIU/mL. Pelvic ultrasound demonstrated trace non-specific fluid (Figure 2). The diagnosis was confirmed histologically.

Decidual cast (DC) is a gynecological phenomenon in which the entire lining of the uterine cavity is shed in one piece, resembling the shape of the uterus.^{1, 2} This condition can be quite alarming due to its dramatic presentation and can be accompanied by significant pain and heavy bleeding. Women may report cramping similar to or more intense than typical menstrual cramps, alongside the expulsion of a fleshy mass. The pathology involves excessive buildup and subsequent detachment of the decidualized endometrial lining under the influence of progesterone.^{2, 3} Hormonal contraceptives, particularly those containing progesterone such as DMPA can predispose to DC.^{1, 4, 3} Diagnosis is clinical, supported by history and physical examination, and may be confirmed by histological examination if the cast is retained for analysis. Our patient's histology showed benign decidualized endometrial tissue with exogenous progesterone effects. Treatment focuses on pain control for abdominal cramping, and patient may continue to use the contraceptive method without further episodes of DC formation.2,5

A 1-month-old male infant presented to a pediatric emergency department with a fever and poor activity. Physical examination revealed tachycardia, slightly mottled skin, abdominal distension, and an umbilical protrusion (Figure 1).

The symptom of umbilical protrusion raised the suspicion of a HPeV3 infection, polymerase chain reaction was performed, and HPeV was detected in the cerebrospinal fluid. A type analysis revealed HPeV3. His general condition, including the umbilical protrusion, resolved after a few days.

HPeV3 can cause a severe infection, such as sepsis or a central nervous system infection, in a young infant.¹ Early diagnosis, though difficult, can enable the discontinuation of unnecessary antibiotic therapy and help predict the clinical course of the infection.

Umbilical protrusion is one of the characteristic symptoms of early infantile HPeV3 infection. In a previous study, eight of 43 young infants with HPeV3 (19%) presented with an umbilical protrusion.² Umbilical protrusion is typically observed in the presence of abdominal distention.³ Abdominal distension caused by HPeV3 is sometimes severe and may be confused with a surgical condition.⁴ The mechanism of umbilical protrusion is thought to be an increased abdominal pressure and the insufficient development of the umbilical ring in young infants. In young infantile cases of abdominal distention and umbilical protrusion accompanied by sepsis-like symptoms, HPeV3 should be considered in a differential diagnosis.

The authors declare no conflicts of interest.

There were no sources of funding for this study.