Journal of Acute Medicine
- OpenAccess
台灣急診醫學會 & Ainosco Press,正常發行
選擇卷期
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Hookworms infection is a soil-transmitted helminthic disease particularly endemic in developing counties of tropical regions. It is attributed mainly to two human pathogens nematodes namely Necator americanus and Ancylostoma duodenale. Although the disease has been characterized as ＂neglected＂ is very difficult to be eliminated and the economic consequences are great. Worms are fed with blood of hosts in small intestine and cause typically iron deficiency anemia with relevant symptoms as well as eosinophilia. Patients admitted in emergency department claim often diffuse general symptoms, whereas cases with obscure gastrointestinal bleeding can be seen. Within this brief review, after introducing some basic elements of hookworms' epidemiology, taxonomy and socioeconomic problem is emphasized, pathogenesis, and life cycle of parasite are concisely explained. Furthermore, clinical manifestations often or rarely seen in emergency department are described. Therapeutic options are also enclosed. Awareness of the problem and critical thinking of patients coming from endemic regions could result to identifying more hookworm cases and their therapy will efficiently alleviate not only the patients per se but health system and societies as well.
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Background: Pregnant patients are at an increased risk for severe morbidity and mortality when compared to the general population. Imaging studies have become an integral part of the work-up for patients who present to the emergency department. However, lack of clear guideline has led to confusion regarding the appropriate indications and protocols for examining pregnant patients. Objective: To investigate the comparative rates of imaging studies between pregnant and non-pregnant female patients who presented for emergent evaluation of chest pain and shortness of breath. Study Design: All reproductive age females presenting to the emergency department at an academic teaching institution with a chief complaint of ＂chest pain＂ or ＂shortness of breath＂ from 2010 to 2015 were identified. Cohorts were divided based on pregnancy status and chief complaint. Utilization rates of imaging studies were compared between cohorts. Results: Over the study period 4,834 women were included. One hundred and seventy-four were pregnant. Pregnant patients with ＂chest pain＂ or ＂shortness of breath＂ were significantly more likely to undergo a venous duplex, but less likely to undergo a chest X-ray as compared to non-pregnant patients. There was no difference in the rates of chest computed tomography (CT) imaging or magnetic resonance imaging (MRI) based on pregnancy status in our data set. Conclusion: Imaging studies are an integral adjunct for evaluation in patients reporting ＂chest pain＂ and ＂shortness of breath.＂ Pregnancy places patients at an increased risk of severe sequelae requiring prompt diagnosis to prevent harm to the mother and fetus. American College of Obstetrics and Gynecology (ACOG) Committee Opinion 656 clearly states that, with few exceptions, radiography should not be withheld from pregnant patients. This study suggests that pregnant patients are significantly less likely to undergo radiography, which could place them at increased risk for delayed diagnosis and treatment.
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Background: The aim of our study was to compare the Age 65; International normalized ratio; Mental status; Shock (AIMS65) score with the Modified Early Warning Score (MEWS), quick Sepsis Related Organ Failure Assessment (qSOFA) score, Glasgow-Blatchford score (GBS), and the complete Rockall score (CRS) in predicting clinical outcomes in cirrhotic patients with upper gastrointestinal bleeding (UGIB). Methods: A total of 442 consecutive cirrhotic patients admitted with UGIB during a 17-month period were retrospectively investigated. The primary outcome was in-hospital mortality. The secondary outcomes were rebleeding, intensive care unit (ICU) admission and development of infection. The area under receiver operating characteristic curve (AUC) for each system was analyzed. Results: For prediction of mortality, the AUC of the AIMS65 score was greater than that of other scoring systems without statistical significance. For the prediction of rebleeding, the AIMS65 score was superior to qSOFA (0.65 vs. 0.56, p = 0.020). For the prediction of ICU admission, the AIMS65 score was superior to the GBS and CRS (0.77 vs. 0.63, p = 0.005 and 0.77 vs. 0.63, p = 0.007, respectively). For the prediction of the development of infection, the AIMS65 score was superior to CRS (0.73 vs. 0.60, p = 0.010). Conclusions: In predicting in-hospital mortality among cirrhotic patients with UGIB, the AIMS65 score showed a trend of better performance than the MEWS, qSOFA score, GBS, and CRS. The AUCs of the AIMS65 score were greater than other four systems in predicting rebleeding, ICU admission and the development of infection.
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Objective: To investigate the clinical predictors for intensive care unit (ICU) admission for patients with benzodiazepine (BZD) overdose and their clinical characteristics in the emergency department (ED). Methods: A retrospective case-control study of acute BZD overdose patients aged ≥ 18 years presenting to the ED in our hospital from July 1, 2012 through June 30, 2015 were enrolled in this study. We collected demographic information on underlying diseases, initial presentations, causes and the classifications of BZD, complications, dispositions, and outcomes. Analyses were conducted among subgroups and were identified the possible predictive clinical factors determining ICU admission in these patients. Results: A total of 140 patients were enrolled in the study, with a mean age of 51.3 ± 19.1 years (mean ± standard deviation [SD]) and female predominance with 2.59:1. The most common cause of BZD overdose was suicidal attempt. The most common underlying disease is major depression disease or bipolar disorder occupying 85.7% of all study patients. Suicide attempt accounted for 84.3% (118/140) of all study patients, among whom 41.4% (58/140) has previous history of suicide attempt. Sixty-nine point two percent (83/120) needed hospital admission, including 20 patients (14.3%) with ICU admission and a total three patients mortalities (2.1%, 3/140). Two clinical predictive factors of ICU admission were identified, including pneumonia and flumazenil use in ED. Conclusion: The incidence of mortality in patients with BZD overdose is low, but all-cause mortality remains high in those admitted to ICU (15%). Emergency physicians are suggested to pay more attentions on BZD overdose patients with suicidal attempt and major depression/bipolar disorder, who have pneumonia or flumazenil use in the ED. The incorporation of hospital healthcare team resource management in dealing with the recording, intervention, and prevention of these patients was mandatory to decrease repeat overdose, enhance care quality, and improve outcomes.
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Early confirmation of tracheal injury is crucial while encountering massive subcutaneous emphysema in emergency department to prevent patients from serious morbidity or mortality. Clinicians often underestimate the difficulty of tracheal intubation, especially for inexperienced physician. We highlight that the use of video laryngoscopy-assisted tracheal intubation or ultrasound for difficult airway management. An 80-year-old woman presented to emergency department because of diffuse subcutaneous emphysema in her chest and neck after multiple attempts of intubation. Subcutaneous crepitus was palpated in the chest and neck. The chest X-ray showed diffuse subcutaneous emphysema in chest wall and neck. The computed tomography revealed paratracheal air, focal defect at right posterior aspect of lower trachea and subcutaneous emphysema, pneumomediastinum and pneumoretroperitoneum. Bronchoscopy demonstrated the presence of 2 cm in length longitudinal laceration wound above the carina. She refused surgical intervention and was treated conservatively. Most patients with tracheal injury may present with subcutaneous emphysema and respiratory distress. Diagnosis could be made based on the findings of computed tomography and bronchoscopy examination. Early recognition could prompt surgical intervention and empirical antibiotics administration to preclude immediate acute respiratory distress.
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Abdominal pain is a very common presenting symptom in the emergency department (ED). To reach an accurate diagnosis one must consider the possibility of multiple conditions that might cause the presenting symptom. We reported a female patient who came to our ED due to aggravated right lower quadrant abdominal pain for several hours. Multiple diagnosis of right T11 herpes zoster, right urolithiasis with hydronephrosis, appendiceal collision tumors of adenocarcinoma arising from adenoma and neuroendocrine tumor as well as leiomyoma in the surrounding adipose tissue were made. Histological examination and immunohistochemistry support these three lesions as separate entities. This case is unique because her multiple combined illness present as abdominal pain. Each one could be the cause of chief complaint, across dermatologic, urologic and neoplastic disorders.
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Inferior mesentery artery (IMA) aneurysm rupture is easily overlooked in patients with abdominal pain due to its uncommon occurrence. It may result in catastrophic consequence once misdiagnosed as spontaneous bowel hematoma in patients with anticoagulant overdose and intra-abdominal hematoma, as treatment strategy for both diseases varies differently. We present a case of a 70-year-old male who came to our emergency department with the chief complaint of abdominal pain over periumbilical area, eventually diagnosed as anticoagulant overdose associated IMA aneurysm rupture without occlusion of superior mesentery artery (SMA) and celiac artery (CA). This case report alerts us to consider the rare other source of bleeding, for instance ruptured inferior mesentery aneurysm, while encountering such an extraordinary large intra-abdominal hematoma in patients on anticoagulant.