Editor- In-Chief: Chien-Chang Lee, MD, ScD Title proper: Emergency Medicine – Open Journal Subject: Medicine Publisher: Openventio Publishers Dates of publication: 2015 Frequency & Medium: quarterly , Online Language: English Country: India Indexed by: CROSSREF , ROAD , THE KEEPERS Title DOI of the Journal: http://doi.org/10.17140/issn.2379-4046
From Neck Pain to a Life-Threatening Condition: A Case Report
A 30-year-old man presented with sudden neck pain radiating to his chest. He appeared anxious, pale, and clammy. Despite unremarkable history and clinical examination, elevated D-dimers led to a computed tomography pulmonary angiography (CTPA), which ruled out pulmonary embolism but revealed a widened ascending aorta. Further family history indicated significant vascular disease in the patient’s father. Initial treatment included analgesia and control of heart rate and blood pressure. The patient was then transferred to a cardiothoracic center, where a detailed CT aortogram and transesophageal echocardiography confirmed an acute type A aortic dissection. This case underscores the diagnostic challenges of aortic dissection, highlighting the need for thorough clinical evaluation and suggesting future use of tools like the Aortic Dissection Detection-Risk Score (ADD-RS) with D-dimers for guidance.
Hypertriglyceridemia-Induced Pancreatitis: A Case Report and Literature Review
Hypertriglyceridemia is the third most common cause of acute pancreatitis. It typically occurs in patients with an underlying disorder of lipoprotein metabolism and the presence of a secondary condition. The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides. This case presents an atypical clinical presentation and one of the highest serum triglyceride levels ever reported. The early recognition of hypertriglyceridemia-induced acute pancreatitis can be complex due to lab interferences but is essential for appropriate management and prevention of recurrence. There is currently no approved treatment guideline available for managing hypertriglyceridemia-induced pancreatitis. Therefore, a literature review was performed. The initial management of hypertriglyceridemia-induced acute pancreatitis includes the treatment of acute pancreatitis with moderate fluid resuscitation, pain control, and nutritional support. The goal is to prevent necrotizing pancreatitis and organ failure by reducing serum triglyceride levels. Specific acute treatment options include insulin therapy, heparin therapy, plasmapheresis, and hemofiltration. Individual therapy should be tailored to each patient and their clinical condition. Diet and lifestyle modification, along with hypolipidemic drugs, prevent further episodes.
West Virginia University Medicine, Wheeling Hospital’s Sepsis Study
Aims To assess if sepsis bundle compliance is associated with all-cause mortality reduction in severe sepsis and septic shock patients. Methods The study focused on adults 18-years and older with a diagnosis of severe sepsis or septic shock. Results The final study cohort consists of 2356 patients who met the inclusion criteria, and close to 76% of the study cohort confirmed compliance with the sepsis bundle. The computed mortality rates for the compliant cohort and non-compliant cohort were 12.3% and 23.6%, respectively (p=1.8×10-6). Is this p-value below 0.05? Conclusion We demonstrated that sepsis bundle compliance is strongly associated with a reduction in all-cause mortality. Importantly, it will be useful to identify further the specific bundle component with the strongest mortality reduction benefit.
Emergency Department Diagnosis and Management of Superior Vena Cava Syndrome Secondary to Hodgkin’s Lymphoma: Case Report and Limited Literature Review of Emergency Department Management
Superior vena cava (SVC) syndrome refers to the obstruction of blood through the SVC with limited case reports and literature reviews of its presentation and management. Here we discuss a 26-year-old male who presented with progressive chest pain and shortness of breath for 5-weeks. The exam showed facial and neck plethora and distension of the veins in the neck and chest wall. This case discusses SVC syndrome due to external compression by Hodgkin’s Lymphoma. The diagnostic approach and the clinical management of superior vena syndrome are reviewed.
Thyrotoxic Periodic Paralysis after Surgery: A Case Report and Literature Review
Thyrotoxic periodic paralysis (TPP) is a rare but potentially life-threatening muscle disease in a thyrotoxic patient. Due to the lack of knowledge, the diagnosis is easily missed. Diagnosis of TPP is made by documentation of hypokalemia and hyperthyroidism in acute generalized muscle weakness. Hypokalemia is caused by an intracellular shift of potassium because of an increased Na-K-ATPase pump activity and the inhibition of the inward rectifying potassium (Kir) channels. The initial treatment aims to treat potentially life-threatening cardiac arrhythmias caused by severe hypokalemia. This can be done with potassium substitution and nonselective beta-blockers, being aware of the potential of rebound hyperkaliemia. Definitive treatment consists of avoiding triggers and correcting the hyperthyroid state with antithyroid drugs, radioactive iodine, or thyroidectomy. Once patients are, permanently euthyroid complete remission of the paralytic attacks usually occurs. We present a case of a 37-year-old male with diffuse muscle weakness after surgery. A new diagnosis of thyrotoxic periodic paralysis was made in the emergency department. This review summarizes the epidemiology, clinical manifestations, pathogenesis, diagnostics, and treatment of TPP.
Analysing the Impact of Large Events on Local Emergency Departments
Every summer, Berkshire plays host to a large event that attracts over 100,000 attendees for a weekend of merrymaking.1 Hosting such a large group of attendees comes with several considerations, one of which is access to medical attention. The local hospital in Berkshire is a district general hospital which has approximately 1000 beds and serves a population of around 500,000 people. It has a well-established emergency department (ED). Attendances to EDs have been increasing annually. This is accompanied by increased pressures, waiting times and need for resources.2 When the population abruptly increases by 20%, measures need to be put in place to manage the demand on healthcare services to ensure that all patients receive safe and effective care both in hospital and pre-hospitally.
A Pre-Hospital Intervention to Alleviate Loneliness and Isolation in Older Adults
Aims The project’s objectives included determining how lonely older folks were in their pre-hospital environment and how much social contact they had. To gauge older individuals’ knowledge of regional programmes to combat isolation and loneliness. Letting elderly folks who could benefit from local services know that they are available. Using pre-hospital efforts to identify and treat patients who are lonely. Methods Thirty (30) patients were recruited whilst on 6 ambulance observer shifts in Berkshire, UK. The ambulance observer shifts took place between January 2023 to February 2023. The patients were asked a simple questionnaire on loneliness and social isolation. At the end of the questionnaire, all patients were offered information leaflets with local services and their contact details that they might find useful to alleviate loneliness and social isolation. Patients were also offered a follow-up telephone call to assess the impact of the intervention or if help was needed with getting in touch with the local services. Results Of the 30 patients interviewed, 15 were male and 15 were female. The youngest patient was 66-years-old and the oldest patient interviewed was 98. The average age was 80.4. Twelve (12) patients (40%) scored 7 and above on the question of ‘How lonely do you feel?’, with 10 being extremely lonely. Fifty percent (50%) of the patients saw their friends or families less than twice a week and 46.6% spoke to their friends and families less than twice a week. Several patients had not had a conversation with friends or family for several weeks, with one response being ‘over 3-months ago’. The vast majority (80%) of patients interviewed did not know that there were charities and local services in place to alleviate loneliness and social isolation. As part of the intervention, patients were offered information leaflets about local services available. These were printed on A4 paper or emailed to the patients if they preferred a digital copy. Conclusion Loneliness and social isolation is an epidemic on the rise amongst older adults, and their effects transcend not only mental wellbeing but physical health as well. Intervening in the pre-hospital setting is pivotal because pre-hospital practitioners are in a unique position to observe and assess patients in their own environment and gather firsth and evidence about the determinants of the patient’s health. The benefits will be multi-fold if we can help patients before they get admitted to hospitals. Apart from the economic benefits of reduced admissions, patients will not be unnecessarily admitted and put at risk of deconditioning or nosocomial infections. Most importantly, these interventions aim to improve the patient’s overall quality of life by enhancing their social connections and reducing loneliness.
A Quantitative and Qualitative Investigation of Factors Associated with Caesarean Section Deliveries in Sri Lanka Assessing National Trends and Views of Local Healthcare Professionals in Colombo in 2015
Background A caesarean section (CS) is an operation to deliver a baby through incisions made to the mother’s abdominal wall and uterus, either before or after labor has started. An emergency CS is performed for certain medical indications such as placenta praevia or umbilical cord prolapse, and it most frequently occurs once labor has started. Elective CS are planned CS. They could be performed for non-medical reasons such as maternal request. Aim CS rates in Sri Lanka have been rising over the past decades. This study investigates reasons for the rise in CS rates through qualitative and quantitative analyses. Methods Qualitative data analysis involved interviews which were conducted in a teaching hospital in Colombo, Sri Lanka. Twenty (20) healthcare professionals in Obstetrics and Gynecology were interviewed. A semi-structured questionnaire, consisting of 15 opened and closed questions, was the basis for the interview. Quantitative analysis was performed on Demographic and Health Survey (DHS) data from 2006-2007. Variables included mother’s age, education level and residence. Chi-squared (χ2) and regression analysis using statistical package for the social sciences version (SPSS) was performed to determine if these variables were associated with CS. Results From qualitative analyses of the interviews, the main themes identified were the healthcare professionals’ views on causes of the rising CS rates, parties involved in the decision-making process, benefits and risks of elective CS and availability of support or alternative options. Quantitative analysis of DHS data showed variables such as residence, province, and education level were significantly associated with CS (p<0.01). Urban residences, living in Colombo and extremes in education levels had the greatest likelihood of a CS. Age, although statistically not significant, is clinically important as literature reviewed showed that CS tend to be more prevalent in extremes of age. Conclusion Analysis revealed the importance of factors associated with CS. Targeting areas that showed the greatest prevalence of CS is an effective strategy to address rising rates.
A Systematic Review of Anesthetic, Saline and Dry Needling Injections for Headache Patients
Objectives Earlier literature provided evidence of neck pain relief via cervical trigger point injections with anesthetic agents. However, recent evidence suggests that intramuscular or paraspinal cervical injections with local anesthetic may provide relief for various types of headaches and orofacial pain as well. The primary purpose of this systematic review was to determine whether a cohort of retrospective case studies and randomized controlled trials using paraspinal cervical or intramuscular anesthetic injections were associated with a decrease in headache and orofacial pain. Methods A systematic review of the literature was performed to observe the association between headache or orofacial pain relief and paraspinal cervical injections with various pain-relieving agents. Literature searches using the key terms “headaches”, “paraspinous cervical injections”, “neck/intramuscular injections” and “orofacial pain” were performed in PubMed, Google Scholar, and Scopus. We implemented the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format for the systematic review. Results Initially, four hundred forty articles were located during the systematic review. Five total articles were selected for review and 435 were excluded because they did not meet search criteria. Another two relevant articles were found during manual searches within references of the systematic review. The seven studies included were retrospective case studies involving patients with headaches or orofacial pain who received paraspinal cervical or other intramuscular injections. A total of 841 patients’ data were tallied from the 7 articles and 683 of those patients received anesthetic injections. Significant pain relief due to intramuscular or paraspinal cervical injections was observed in 83.7% of the patients. Conclusion Our systematic review of association between headache or orofacial pain relief and paraspinal cervical injections with various pain-relieving agents demonstrated a frequency of headache and orofacial pain relief of 83.7%. Such a large percentage compared to a robust placebo study provides promising evidence that this treatment may have a therapeutic role in the management of headache and orofacial pain. Despite limitations faced in performing our systematic review, it seems quite clear that pain relief for these headache patients can be attributed to intramuscular anesthetic or dry needling injections. While larger prospective studies should be performed regarding specific location and anesthetic, our systematic review provides additional evidence that anesthetic intramuscular and dry needling injections provide pain relief intension-type headaches (TTH), migraine headaches, cervicogenic headache pain, and orofacial pain.
Recombinant Human Lactoferrin: An Opportunity to Treat the Neonatal and Adult Severe Sepsis
Lactoferrin, both human and bovine, acts against oxidative stress damage and has a range of beneficial activities such as antipathogenic, anti-cancer, anti-inflammatory, immunomodulatory, and deoxyribonucleic acid (DNA)-regulatory. In addition, clinical studies have shown human lactoferrin to attenuate inflammation and reduce mortality from neonatal and adult severe sepsis. However, the magnitude of the lactoferrin effect varies between studies. Given the demonstrated efficacy of recombinant human lactoferrin in sepsis, its lack of side effects, ease of administration, and relatively low cost, it is worth exploring whether the protein could be administered “preventively” as soon as the possibility of a patient’s condition progressing to severe sepsis is likely.
Airport Personnel and Coronavirus Disease-2019: A Seroprevalence Study in Taiwan
Introduction Many countries tried to lifted the travel restriction to revive their stagnant tourism-based economies. However, infection risks among airport personnel are incompletely understood. We therefore conducted this seroepidemiological study targeting airport personnel. Methods This cross-sectional study was conducted from October 20th, 2020 to February 28th, 2021 at the Taoyuan International Airport in Taiwan. All adults who worked at Taoyuan International Airport and were older than 20-years of age were eligible for participation. Serological tests were collected and study participants were asked to complete an online questionnaire which collected selfreported data including demographic characteristics, occupation, exposure risk assessment, recent symptoms, and self-perceived risk of infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Continuous data were expressed with median and interquartile ranges; categorical data were expressed with counts and proportions. Results A total of 450 volunteers agreed to participate in the study. Most of the participants worked as ground crew (40.7%). Approximately 43.6% of participants did not feel any symptoms in the 3-months prior to serologic testing. Only 8 participants (1.8%) reported close contact with confirmed coronavirus disease-2019 (COVID-19) cases. Overall, none of the study participants had serologic confirmation of immunoglobulin G (IgG) antibodies against SARS-CoV-2. Conclusion The SARS-CoV-2 infection rate among airport personnel was low. This study demonstrates that a well-designed border control strategy may work and so that transmission of SARS-CoV-2 may be controllable.
Forty-Four Questions I Would Like to Ask Bronchiolitis Guideline Writers and Researchers
As a clinician and academician with front-line experience in the management of the bronchiolitis syndrome, I have previously published opinions about the bronchiolitis guidelines.1,2 It is obvious that the de-implementation movement initiated by the bronchiolitis guidelines has not gone as planned. In the United States substantial elements of the bronchiolitis guidelines are generally not being followed in outpatient settings, emergency departments and pediatric intensive care units.3-6 Guideline non-compliance is also a conspicuous international problem.7-11 Studies attempting to understand the factors behind and to mitigate apparent resistance to the guidelines have been published.4,12,13 Other published studies have focused on strategies to maximize de-implementation.14-21 Unfortunately, the bronchiolitis guidelines were challenged from the start by inpatient versus outpatient bias, lack of clarity or confusion over the disease definition, failure to address clinical distinctions between undifferentiated outpatients versus inpatients, the failure to provide management recommendations for bronchodilator responsive bronchiolitis look-a-like conditions and the de-implementation recommendations based on incomplete research of the only therapeutic tools available to the front-line provider.
The Effect of Complexity of Ambulance Missions on Shared Mental Models in Virtual Teams
Background Empirical research on shared mental models (SMM) in virtual environments are almost non-existent. Pre-hospital emergencies presents an opportunity to examine team processes in virtual teams because the dispatcher is geographically separated from the ambulance and at the same time plays a significant role in coordinating, organizing, obtaining, evaluating, and conveying relevant information to the deployed ambulance. The present study aimed at mapping team behavior and cognition in critical real-life emergency medical missions based on the concept of SMM. Methods By investigating the frequencies of coordinating mechanisms and team competencies based on voice recordings from real-life missions, differences in team behavior between low and high-complexity missions were investigated. Results Lower frequencies of team competencies and coordinating mechanisms were found in high compared to low-complexity missions. The results showed a different profile in communication between high and low-complexity missions with more frequent use of both coordinating mechanisms and team competencies in low-complexity missions. Furthermore, the profiles revealed that SMM and closed loop communication were the only coordinating mechanism used, and leadership and team orientation were the only competencies exercised. Conclusion It was concluded that the lack of visual input of a team member during team interaction could lead to team process loss due to a breakdown of the team into sub-units. Potential improvement of team behavior is discussed within the SMM framework.
The Prevalence of Pathologic Q Waves on Electrocardiograms of Pediatric Patients with Confirmed Hypertrophic Cardiomyopathy: A Systematic Review of the Literature
Objectives The electrocardiogram (ECG) of patients with hypertrophic cardiomyopathy (HCM) ranges from normal to exhibiting evidence of ventricular hypertrophy, including pathologic Q waves and ST-T wave changes. Deep Q waves in the inferior and lateral leads are one of the classic ECG findings associated with HCM. The prevalence or frequency of this finding in pediatric HCM patients, however, is not well-established. Furthermore, other pediatric health conditions have also been associated with pathologic and non-pathologic Q waves and an awareness of those conditions is important to consider when Q waves are observed. The primary goal of this systematic review of the literature is to describe the prevalence of pathologic Q waves in the ECGs of pediatric patients with echocardiogram proven HCM. A secondary goal is to review other pediatric conditions that can present with pathologic and non-pathologic Q waves. Methods The databases PubMed, Web of Science, Scopus and cumulative index to nursing and allied health literature (CINAHL) were searched utilizing the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format. The Rayyan systemic review software was used to screen articles for final review. The initial search (Search 1) consisted of the following terms: “dagger Q wave”, “dagger-like Q waves”, “dagger shape Q waves”. Subsequently, a broader search (Search 2) was conducted to determine if viable articles were omitted in the first search. This broader search strategy eliminated the term “HCM”. The authors then performed detailed review of the articles these two searches yielded, as well as a review of the references of these articles to find other relevant articles as well as produce a list of other pediatric conditions that may be associated with pathologic or nonpathologic Q waves. Results Of the articles found via the three searches, a total of nine English language articles that specifically addressed the prevalence of pathological Q waves in pediatric HCM patients were ultimately included in our systematic review. These nine articles described a total of 845 pediatric patients with HCM. Of these, 258 (30.5%) demonstrated pathological Q waves on their electrocardiograms. The range of percentages reported for pathological Q waves was 12.5 to 66.7%. Additionally, our review found fifteen different pediatric conditions reported to be associated with pathologic or non-pathologic Q waves. Conclusion Our systematic review confirmed that pathologic Q waves are a common and early electrocardiographic finding in children with HCM and may, in fact, be the only ECG finding. In addition, our review provided an extensive list of other pediatric diseases and conditions associated with pathologic or non-pathologic Q waves on the electrocardiogram.
Extra-Pulmonary Manifestations of Coronavirus Disease 2019: A Multi System Disease
Introduction The outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV- 2), has been recently declared a pandemic by the World Health Organization. Apart from acute respiratory manifestations, SARS-CoV-2 may also adversely affect other organ systems. To date, however, there is a very limited understanding of the manifestations and management of COVID-19 related conditions outside of the pulmonary system. This study provides an overview of the current literature about the extra pulmonary manifestations of COVID-19 that may affect the renal, cardiovascular, gastrointestinal, hematological, hematopoietic, neurological, or reproductive systems. This study also describes the current understanding of the extra pulmonary manifestations caused by COVID-19 to improve the management and prognosis of patients with COVID-19. Materials and Methods A total number of 200 hospitalized patients with COVID-19 disease were retrospectively evaluated for extra-pulmonary manifestations findings or complications. These patients had undergone various imaging studies, blood examinations during the course of hospital stay. The data reviewed using the institutional PACS, database system over a period of four months (August to November 2020). Results Among the 200 patients (males and females), 175 of them had extra-pulmonary complications. Various extra-pulmonary findings such as acute kidney injury, renal failure, cytokinase strome, acute myocardial injury, congestive cardiac failure, pulmonary thromboembolism, gastrointestinal, neurological complications were observed. Inclusion and Exclusion Criteria All retrospective clinical studies, case series, and case reports with data on extra-pulmonary manifestations in COVID-19 that were published from the end of December 2019 till the end of February 2021 were included. Studies that did not mention extrapulmonary manifestations were excluded. Literature Search The review was based on publications available on PubMed and data collected by the World Health Organization (WHO). Search terms used were ‘novel coronavirus 2019 (2019-nCoV)’, ‘SARS- CoV-2’, or ‘COVID-19’ combined with ‘asymptomatic’, ‘gastrointestinal’, ‘cardiac’, ‘neurological’, ‘hepatic’, ‘hematological’, ‘renal’, ‘psychiatric’, ‘hematological’, and ‘atypical’.
Legalities in All Wound Care Negligence of Care
Wound care costs in the United States exceeds 10 times more than that of other countries.1 Legal suites are increasingly paid out by clinicians, not the hospitals or the healthcare system.2 Many clinicians are facing lawsuits for malpractice or professional neglect. When taken to court and found guilty, the judgment will result in a large settlement then include the loss of the clinician’s license.1 Since malpractice has a limited judgement, many lawyers are seeking damages as a result of elder abuse. In using elder abuse, the judgements do not have a limitation and often result in very large settlements.2 Clinicians need to learn how to protect him/ herself from lawsuits and present the best defense. Areas of negligences in care are: 1) Failure to follow the provider’s orders. 2) Failure to properly monitor and observe the patient and the progress of the wound, 3) Failure to report changes in the patient’s condition. 4) Failure to properly document wound assessment properly and with true description.2 The following paragraphs will explain these failures in greater detail.
Prolonged Cardiac Arrest in Severe Bupropion Intoxication: Everything You Should Know About Anti-Arrhytmics, Transesophageal Echocardiography Guided Resuscitation and Extracorporeal Membrane Oxygenation
A 30-year-old woman was admitted to the emergency department one and half hours after severe bupropion extended-release intoxication, estimated to be between 18 and 36 g. She initially presented with seizures and later developed signs of cardiotoxicity with persisting sustained ventricular tachycardia. Despite multiple defibrillation attempts and the administration of sodium bicarbonate, calcium gluconate and magnesium, restoration of sinus rhythm was found unsuccessful. In another attempt to treat this refractory ventricular tachycardia lidocaine was given followed by deterioration to asystole. During cardiopulmonary resuscitation (CPR), the quality of chest compression was assessed and optimised using transoesophageal echocardiography. Eventually venoarterial extracorporeal membrane oxygenation (VA-ECMO) was needed to achieve hemodynamic stability. In this case report we discuss the successful use of VA-ECMO after bupropion intoxication, which has only been reported in 3 other cases but should be considered as one of the treatment options in severe overdose cases. Also, the rare complication of asystole after lidocaine administration and the value of transoesophageal echocardiography during CPR will be discussed.
Ultra-Early Cord Decompression in the Emergency Setting and its Impact on Outcome
Background Traumatic cervical are injuries are very common due to high motility of cervical spine and its vulnerability to traumatic injuries. Optimal time for stabilizing the patients with traumatic spinal fractures remains controversial. It is almost due to different outcomes in various studies and the lack of consensus about it. Here we explain an ultra–early cord decompression that led to complete recovery of a patient with severe cervical cord injury. Case Presentation The patient was a 27-year-old gymnast woman with a recent history of spinal cord injury caused by high jumping with head back and neck hyperextension presented within 2-hours of trauma. As a critical case and lack of advanced radiologic equipment, only cervical spinal radiographs were used for decision-making within the first 3 hours of injury to save the patient’s cord function by surgical decompression. Conclusion Many studies have proposed different intervention times for achieving the optimal result; however, we present an ultra-early surgery (within 3-hours of injury), conducted in a context of limited medical facilities. This case revealed an excellent result after 12-months follow-up.
Vertebral Artery Dissection Mimicking Migraine: A Case Report
Vertebral artery dissection (VAD) is caused by an intimal tear that leads to bleeding into the vascular wall, which may cause vascular occlusion by thrombus formation and subsequent distal emboli (leading to ischemic stroke), aneurysm formation and subarachnoid hemorrhage. Cervical artery dissections (either carotid or vertebral artery dissection) are an important cause of stroke in patients under 50-years of age. Headache with or without neck pain is a common symptom. Usually, it occurs with focal neurological signs but sometimes it may occur without any neurological deficits and may mimic migraine. Often it occurs spontaneously without trauma but sometimes there is history of minor traumas, sudden neck movements or chiropractic manipulation. Imaging modalities include magnetic resonance imaging (MRI) brain, magnetic resonance angiography (MRA), and computed tomography angiography (CTA). Treatment involves anticoagulation or antiplatelet agents.
Electrical Injury and Prolonged Cardiac Arrest: A Case Report of Complete Neurological Recovery
Introduction Sudden cardiac arrest continues to have a high mortality rate. Out of hospital cardiac arrest (OHCA) has a poor outcome compared to those occurring in a healthcare setup due to lack of awareness and appropriate resources. The most common rhythm abnormality in OHCA is ventricular fibrillation which requires early defibrillation, ideally on the location. Case Report A 19-years male was witnessed by lay bystanders to have become unresponsive following contact with an electric lighting pole on the road median in Chandigarh. A passer-by medical resident detected no pulse and initiated chest compression. Since there was no immediate return of spontaneous circulation and aetiology suggested a defibrillate rhythm. The patient was taken in the car and rushed to a tertiary care centre, 10-minutes away. Cardiopulmonary resuscitation (CPR) was interrupted during transport for lack of adequate personnel. Ventricular fibrillation was noted and shock was delivered along with inotropes. Around 26-minutes into the resuscitation, the patient had the return of spontaneous circulation. After post-cardiac arrest care in intensive care unit (ICU), he was extubated and discharged home in 1-week with full neurological recovery. Discussion Recovery of full neurologic function could be explained by the alternating presence of stable and unstable cardiac rhythms and in part at least brought about by immediate attempts at resuscitation. The report seeks to review these aspects of emergency care besides highlighting the need for both immediate and accurate emergency medical services such as lay responder training, public access defibrillation and responsive transport systems for such patients.
Macroscopic White Blood Cell Casts: An Extremely Rare Presentation of Klebsiella Pyelonephritis
In this case report, we present a patient with severe pyelonephritis who presented complaining of passing worm-like tissue from his penis. This patient was passing macroscopic ureteral white blood cell casts resulting from a severe pyelonephritis caused by Klebsiella pneumoniae.
Nebulized Tranexamic Acid for Hemoptysis
The synthetic antifibrinolytic drug, tranexamic acid, is widely used intravenously, orally and topically to treat various bleeding complications. In recent years, there has been increasing evidence of its use as inhalation drug for hemoptysis. In this review, the available literature about aerosolized tranexamic acid is listed.
A case was reported in the wake of stepping on a sharp nail in a board where the patient was given a Tetanus shot and sent home with advice to apply triple antibiotic cream twice a day and wrapping the injury with gauze along with oral antibiotics. The patient was suggested to soak his foot in Dakin’s Solution.. The patient returns after 2 weeks to the emergency room (ER), limping and not bearing weight on the injured foot. The patient states that he had been doing the dressing changes and noted the area was becoming odorous. He was unable to walk on the foot or get his boots on for work. The foot was swollen and odorous with an enormous amount of discharge from the wound. The foot was soaked in Dakins by the staff. The surgeon was called and the ulcer was examined. Upon instruction, an magnetic resonance imaging (MRI), culture, labs, intravenous (IV) antibiotics, and admission, with surgery scheduled for in AM. The patient was found to be diabetic. Aware of this the surgeon and the internist assigned to the case, continue the work on to include a cardiologist and vascular surgeon. . Amputation was performed which led to a major change in the patient’s life. The patient failed to return to his previous occupation and could not support his family.
A Decision Support System is Needed for Rapid Triage of Chest Pain Patients Using High Sensitivity Troponin Testing-Based Algorithms
Cardiovascular disease is a leading cause of mortality and morbidity worldwide. In 2013, an estimated 8.14 million people died from acute myocardial infarction (AMI) globally.1 Emergency department (ED) is the main portal of entry for patients with acute chest pain symptoms. Approximately 10% of all emergency department (ED) patients presented with chest pain complaint.2 However, only 13-23.6% of these patients are finally diagnosed with AMI.3 Patients with segment (ST) elevation MI (STEMI) could be rapidly recognized by electrocardiogram (ECG) exam, but patients with non-ST elevation MI (NSTEMI) could not be efficiently excluded or included by contemporary cardiac troponin assays. Contemporary troponin assay could not detect the presence of cardiac troponins in the peripheral circulation until 6 to 8 hours after the onset of MI.4 Therefore, patients presenting to the ED with chest pain usually require serial troponin measurements over 6 to 8 hours before the possibility of MI can be safely excluded. Failure in early detection results in higher rate of complications and mortality. The delay in ruling out MI constitutes a major cause of ED crowding, and the delay in ruling in MI may lead to poor prognosis. It has been shown early evidence-based management, including antiplatelet treatment and revascularization, may decrease mortality, shorten hospitalization, and improve overall outcome.
Dealing with Violent Dangerous Patients: The Medicolegal Pitfalls
“Takedown” in the Emergency Department (ED) an all too regular occurrence that is set to escalate dramatically in years to come. This was prophesized by a newspaper headline from 1991, “The growing ranks of aggressive, addictive and deranged people for whom the emergency department is the last resort.”1 Making the call to “Take someone down” in the ED is never to be taken lightly. The only time such a drastic decision should be made is to prevent imminent harm to the patient or others. It should always be the most senior doctor in the department at the time who makes the clinical decision that the physical and/or chemical restraint of a person is necessary and sanctioned by law at that time. This area is a minefield for doctors. The duty of care of the physician is in direct conflict with the patient or violent person’s right to bodily integrity, freedom of movement, freedom from bodily infringement, refusal to consent to medication, and several other inherent civil liberties that every person has as an automatic right to.
Prothrombin Complex Concentrates in Post-traumatic Hemorrhage: A Review
Prothrombin complex concentrates (PCC) has long been used to reverse vitamin K antagonists (VKA)-induced coagulopathy rapidly and safely. However, its use in trauma-induced coagulopathy (TIC) in patients not using VKA drugs is yet to be elucidated. This article is a narrative review and analysis of the most recent literature to analyse consequences, and intended effects associated with this treatment modality in TIC. Utilization of PCC was addressed in the literature data found by searches of databases. The indications, efficacy and outcomes associated with the use of the product were reviewed in the articles. Some studies point out promising results with respect to PCC use to overcome the VKA-related coagulopathy in victims of trauma. PCC may be a viable option for resuscitation in emergency and critical care in the management of severe hemodynamic deterioration induced by trauma, despite contradictory findings in the literature.
This present study aimed to evaluate a group of patients living in a rural area admitted to emergency room due to animal-related injury and to evaluate this issue from a general point of view. Material and Methods The study included 34 patients between the dates April 2015 and April 2017. The injury caused by donkey, horse, and cattle was considered animal-related injury. The demographic features, blood tests, imaging tests, hospitalization status and outcomes of patients were evaluated retrospectively. Results Of the 34 patients, 32(94.1%) were male. The mean age of the patients was 27.56±21.72 (min:5-max:83). The youngest patient was five and the oldest one was 83-years-old. Three patients were over 65-years. Eight of the patients (23.5%) were hospitalized. The average hospitalization day of the patients was 4.53±3.46 (min:0-max:10). Acute pathology was detected on cranial tomography six of the patients (17.6%). None of the patients had pathology on cervical tomography. Acute pathology was detected on thoracic tomography five of the patients (14.7%). Acute pathology was detected on abdominal tomography four of the patients (11.8%). Conclusion In conclusion, people living in rural areas should be informed about animal-related injuries. The arrangements should be made to prevent these injuries in rural areas.
Cardiopulmonary Resuscitation: To Intubate or Not to Intubate
Cardiopulmonary resuscitation (CPR) is a “tug of war” between life and death. The most suspenseful and technically difficult task in the resuscitation process is often endotracheal intubation. However, the benefits of endotracheal intubation during CPR have been seriously challenged in recent literature.
Diagnostic Advances in Acute Viral Meningitis: Any Novelty for the Physician?
Acute viral meningitis (AVM) constitute an important cause of mortality and neurological morbidity within the last decades, in spite of all diagnostic and therapeutic advances in medical technology. Diagnostic procedures consist of lumbar puncture, hemoculture, complete blood cell count (including, leukocytes), procalcitonin, lactate and glucose to give an overall insight for disease; while polymerase chain reaction (PCR) and cerebrospinal fluid (CSF) analyses (urine reagent strips, glucose, protein, and microscopic examination) are used to diagnose herpetic meningeal involvement and most other viral infections affecting central nervous system (CNS). Findings in blood and CSF work-up after a clinical index of suspicion result in a high yield of diagnosis. Technological advances should be coupled with clinical findings to produce an accurate clinical management in the target population. This review is intended to analyze the epidemiology, clinical manifestation, findings on examination, and diagnostic tools to be utilized in patients suspected to have AVM in light of recent advances and research data, and to culminate up-to-date concept of AVM for primary care and emergency physicians.
Long Working Hour Related Medical Errors and Patient Outcomes among Physicians: A Systematic Review
Inspired by the famous Libby Zion case in 1984, which revealed the underlying flaw in the medical system at the time──the exploitation of junior medical staff and the inadequate surveillanceby attending physicians, authors of this systemic review aim to investigate the potential consequence of overworking in medical scenarios. Methods Excerpta medica database (EMBASE) and PubMed had been systematically searched, bibliographies of relevant studies additionally reviewed. Four cohorts and three randomized controlled trials were selected and quality-assessed with Newcastle-Ottawa Scale and the Cochrane risk of bias tool, respectively. Literature were extracted and discussed. Results Two randomized controlled trials have concluded that residents or interns with longer consecutive working hours per shift in the division of internal medicineare prone to more medical errors. One cohort study has shown a significant association between longer weekly working hours and worsened quality of patient care (intensive care unit (ICU) transfer rates and in-hospital mortality) in the setting of internal medicine. However, none of the 3 studies which were conducted in surgical departments suggests a further restriction on weekly working hours or shift length. Conclusion The specialty-specific policy is recommended based on our between-study comparison. Specifically, with respect to the incidence of medical errors or adverse events, weekly hours or shift length are weakly recommended to be regulated in the department of internal medicine, but there is no recommendation to surgical departments. However, one must consider all respects of the impact brought by any alternation of working policy before the actual implementation.
Accreditation council for graduate medical education (ACGME)