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

A 52-year-old woman presented to the emergency department with 3 days of abdominal pain. The pain began 1 day after undergoing a screening colonoscopy. On examination, her vital signs were normal and she had significant tenderness to the lower abdomen. Laboratory work revealed a white count of 22 K/µL and a normal lactate (0.8 mmol/L). An upright chest and abdominal x-ray were normal. Computed tomography (CT) of the abdomen with intravenous (IV) contrast was then performed.

Intestinal perforation is a potentially life-threatening complication that may arise from diverse etiologies, including instrumentation.^1-4 The initial step in workup of suspected intestinal perforation is often looking for free air under the diaphragm on an upright abdominal x-ray to evaluate for pneumoperitoneum.¹ We would not see this finding in our patient because she had pneumoretroperitoneum, where the gas pattern is different from that of pneumoperitoneum.⁵ Ultimately, CT scan showed retroperitoneal air tracking along the aorta and inferior vena cava (IVC) (Figures 1 and 2). She underwent exploratory laparotomy with creation of a diverting end descending colostomy.

Colonoscopy-related perforation (CRP) is rare; the incidence ranges from 0.016% to 0.2% following diagnostic procedures and up to 5%, if the colonoscopy is therapeutic.^2-4 Rectal perforations, as in this case, have been reported to have an incidence ranging from 0.003% to 0.01%.^{2, 6} CRP can be managed conservatively or surgically. It is important to note that up to 31% of patients with CRP present for treatment more than 24 h after their colonoscopy.^{3, 4}

A 75-year-old man presented to the emergency department with intermittent right upper quadrant abdominal pain for 6 months and newly onset vomiting for 1 day. Two days prior, he received an abdominal ultrasound showing extensive cholecystolithiasis. Clinical examination showed mild tenderness in the right abdomen without peritonitis. Blood test results revealed moderately elevated inflammatory markers as follows: white blood cell (WBC) count 15.44 g/L and c-reactive protein (CRP)  43.4 mg/L. Liver parameters were within normal range. Bedside ultrasound was performed showing a stone-free gallbladder, non-dilated bile duct (Figure 1, panel A), and distended small bowel (Figure 1, panels B and C). Accordingly, computed tomography (CT) was performed (Figure 2).

The authors declare no conflicts of interest.

The authors received no financial support for the research, authorship, and/or publication of this article.

A 62-year-old male with a history of alcoholic cirrhosis with esophageal varices presented with a chief complaint of hematemesis and abdominal distention. Examination demonstrated ascites and a long-standing umbilical hernia. Given the patient's worsening pain and ongoing hematemesis, point-of-care ultrasound (POCUS) was utilized (Figure 1), which revealed the diagnosis, and was later confirmed with a contrast-enhanced computed tomography (CT) (Figure 2).

In this case, POCUS was utilized and accurately identified a closed-loop bowel obstruction suspended in the ascites fluid (Video 1). A contrast-enhanced CT confirmed an incarcerated umbilical hernia, and the patient was brought to the operating room for an umbilical hernia repair and small bowel release, as well as gastrointestinal consultation for possible esophageal variceal bleeding.

The current gold-standard imaging modality for small bowel obstruction (SBO) is CT imaging. This case demonstrates the utility of POCUS in the diagnosis of SBO at bedside (Video 2). Considering his extensive history of high-risk cirrhosis leading to hematemesis and a challenging abdominal examination revealing long-standing ascites, treating physicians may face the risk of anchoring bias, potentially narrowing their focus on the possibility of esophageal variceal bleeding. POCUS quickly revealed the additional pathology, with the obstruction evident within the ascites. POCUS has also demonstrated a significant reduction in time to imaging completion when utilized for bowel obstructions, potentially leading to shorter time to surgical intervention.¹ Depending on certain clinical factors, some patients may be able to forego CT scans after demonstration of an obstruction process on POCUS.²

All authors contributed significantly to the preparation of this report.

The authors declare they have no conflicts of interest.

The authors received no specific funding for this work.

A 17-year-old male with juvenile nasal angiofibroma and intracranial extension underwent tumor excision with dural repair and skull base defect reconstruction using flap, presented with meningismus a year later. Initial computed tomography (CT) scan showed features of meningitis in the form of diffuse sulcal effacement and subtle leptomeningeal enhancement (Figure 1). A lumbar puncture (LP) was performed to obtain cerebral spinal fluid (CSF) for microbiology and biochemical tests. Deterioration of his neurological status approximately 1-week post-procedure prompted an magnetic resonance imaging (MRI) evaluation that revealed multiple susceptibility artifacts on susceptibility-weighted sequences (See Figure 2A and B), which corresponded to pneumocephalus, pneumoventricle, and pneumocistern on CT (See Figure 2C and D). Nasal endoscopy and MRI cisternogram were negative for any fistula. The patient improved symptomatically after 2 weeks with conservative management. Follow-up study showed complete resolution of the findings.

Initial CT being negative for air (Figure 1), followed by LP-induced pneumocephalus, postulates two possible theories. First is a possible occult, one-way dural fistula at the surgical site leading to slow air entry post-LP into the subarachnoid space due to the over-drainage of CSF, which may have led to intracranial hypotension. This fistula was not detected on the endoscopy or MR cisternogram possibly because the procedures were performed without pressurization of air spaces. The second possibility is accidental injection of air into the subarachnoid space during LP.¹ Considering the amount of air in this case, the second mechanism appears more likely (See Figure 2

Subarachnoid pneumocephalus is mostly asymptomatic unless large and resolves spontaneously within 1–2 weeks. Treatment with high concentration of oxygen may also hasten recovery.² While raised intracranial pressure is not an absolute contraindication to lumbar puncture, a controlled drainage with minimum effective amount should be performed in these patients as over-draining CSF may lead to side effects such as post-dural puncture headaches, or air entry into the subarachnoid space through the spinal needle or any indolent surgical site fistula.

The authors declare no conflicts of interest.

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