Journal of emergency and critical care medicine (Hong Kong, China)最新文献

{"title":"Pathophysiological determinants of arterial carbon dioxide tension (PaCO2) in spontaneously breathing and mechanically ventilated patients","authors":"S. John, R. Ozanne, K. Ho","doi":"10.21037/JECCM-21-7","DOIUrl":"https://doi.org/10.21037/JECCM-21-7","url":null,"abstract":"© Journal of Emergency and Critical Care Medicine. All rights reserved. J Emerg Crit Care Med 2021 | http://dx.doi.org/10.21037/jeccm-21-7 Changes in PaCO2 in hospitalised patients are common and associated with an increased risk of morbidity and mortality. Although many clinicians are aware of the physiological mechanisms for PaCO2 homeostasis, they often have difficulty understanding how different compensatory mechanisms interact, and why such interactions are not always successful in achieving normocapnia. Incorrect interpretation of PaCO2 level—even when it is within the normal range—can have dangerous consequences in a spontaneously breathing patient (1). In this correspondence, we briefly describe how we can visually interpret the interactions of different pathophysiological mechanisms in determining PaCO2 in a spontaneously breathing or mechanically ventilated patient. In a spontaneously breathing patient, there are two determinants of PaCO2. The respiratory drive from the brain is an active system (which can increase minute ventilation up to 10 L/min for every 3 mmHg PaCO2 increment unless PaCO2 is exceedingly high) (1); whilst the mathematical relationship between alveolar CO2 tension (or PaCO2 for simplicity), carbon dioxide production (VCO2 ~200 mL/min for an average adult that can increase up to 10 folds with vigorous exercise) and minute alveolar ventilation represents a passive system (Figure 1A) (2). Minute alveolar ventilation is equal to the minute ventilation minus the wasted ventilation due to the physiological dead space which is the sum of anatomical and alveolar dead space. The interaction between the active and passive systems defines the PaCO2. An increase in respiratory drive due to hypoxia or metabolic acidosis will increase the ‘slope’ of the active respiratory drive system, resulting in an increase in minute ventilation which will reduce PaCO2. As such, a PaCO2 within the normal range is actually abnormal in the presence of significant metabolic acidosis, and would signify concomitant respiratory drive depression (1). Respiratory depression due to opioids and sedatives will shift the active respiratory drive system to the right (Figure 1B), resulting in a lower minute ventilation and a higher PaCO2. An increase in VCO2 will shift the passive system upward, resulting in a higher PaCO2, until the active respiratory drive system shifts the slope upward to normalise the PaCO2 (Figure 1C). An increase in alveolar dead space—which can occur due to emphysema, reduced pulmonary blood flow without a corresponding reduction in ventilation or overventilating poorly perfused alveoli [i.e., ↑ overall ventilation to perfusion (V/Q) ratio], ↑ V/Q heterogeneity in acute respiratory distress syndrome (ARDS) and pneumonia (3), or attenuation of the normal hypoxic pulmonary vasoconstriction due to oxygen supplementation)—will shift the passive system to the right, resulting in a higher PaCO2 (Figure 1D). Acute pulmonary embolism would th","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-04-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46749026","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}

{"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}

{"title":"Predicting open wound mortality in the ICU using machine learning.","authors":"Ronald K Akiki,&nbsp;Rajsavi S Anand,&nbsp;Mimi Borrelli,&nbsp;Indra Neil Sarkar,&nbsp;Paul Y Liu,&nbsp;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}

{"title":"Subcutaneous and mediastinal emphysema, uncommon complications of COVID-19 ARDS: a case series","authors":"P. Clark, S. Yohannes, A. Pratt","doi":"10.21037/JECCM-20-149","DOIUrl":"https://doi.org/10.21037/JECCM-20-149","url":null,"abstract":"Coronavirus disease 2019 (COVID-19) adult respiratory distress syndrome (C-ARDS) has led to ventilator related complications such as ventilator associated events (VAE), venous thromboembolic events (VTE), barotrauma, and ultimately profound diffuse pulmonary fibrosis. Barotrauma is one such complication, with reports of spontaneous pneumothorax (PTX) and pneumomediastinum. We present a case series of four patients with severe C-ARDS, complicated by subcutaneous emphysema and mediastinal emphysema with and without pneumothroracies, which required supportive care, except one patient with PTX. Of the four patients only one patient was discharged alive. C-ARDS can induce lung injury, resulting in subcutaneous and mediastinal emphysema, which may not represent a PTX as etiology. The exact mechanism of subcutaneous emphysema and mediastinal emphysema without pneumothoracies in the setting of severe C-ARDS has not been clearly elucidated. Two plausible mechanisms may be related to the “Macklin effect” vs. type I and II pneumocyte breakdown when infected by COVID-19. Strategies used to minimize worsening of subcutaneous and mediastinal emphysema with and without pneumothoracies, may be to minimize positive end-expiratory pressure (PEEP), continue to maintain a lung protective strategy (LPS), while utilizing a higher fraction of inspired oxygen (FiO2) concentration. In the majority of cases, supportive care is usually required, unless PTX presents or tension pneumomediastinum develops, at which time treatment with a thoracostomy tube placement may be necessary or cardiothoracic surgery consultation may be warranted, to perform “gills” procedure. © Journal of Emergency and Critical Care Medicine. All rights reserved.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-03-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43704792","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}

{"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}

{"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}

{"title":"Severity of illness scores at presentation predict ICU admission and mortality in COVID-19.","authors":"Erin M Wilfong,&nbsp;Christine M Lovly,&nbsp;Erin A Gillaspie,&nbsp;Li-Ching Huang,&nbsp;Yu Shyr,&nbsp;Jonathan D Casey,&nbsp;Brian I Rini,&nbsp;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}

{"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}

{"title":"Atypical clinical presentation of inflammatory marker negative septic arthritis, osteomyelitis, and bacteremia following a single dose of tocilizumab in the treatment of COVID-19: a case report","authors":"J. Reyes, E. Ogele, W. D. Clapp","doi":"10.21037/jeccm-21-121","DOIUrl":"https://doi.org/10.21037/jeccm-21-121","url":null,"abstract":"Background: Tocilizumab is an immunomodulating agent that inhibits the inflammatory cascade via interleukin-6 (IL-6) signaling. A recent meta-Analysis written by the World Health Organization, and other large, randomized trials, have found that the medication results in reduced all-cause mortality in the treatment of severe coronavirus disease 2019 (COVID-19) illness, likely by targeting aberrant inflammatory pathways. With the medication now recommended by infectious diseases societies in the treatment of COVID-19, many providers will begin using this medication in critically ill patients, and for some it will be their first exposure to the medication and its side effects. Although atypical secondary infections have been observed following multiple administrations of tocilizumab, our case is significant as it displays an atypical presentation of invasive bacterial illness and sepsis following a single dose. Case Description: Our case consists of a 52-year-old man with severe COVID-19 pneumonitis who was given tocilizumab due to worsening respiratory status and elevating inflammatory markers, who later developed severe, invasive bacterial disease with minimal objective findings suggesting severe illness. Six days following tocilizumab administration, the patient was diagnosed with Staphylococcus aureus (S. aureus) bacteremia, septic arthritis, and osteomyelitis, at which time inflammatory markers were within normal limits, he was no longer febrile or tachycardic, and his only objective findings suggesting illness were a tender shoulder with an isolated, neutrophilic predominant leukocytosis. This complication resulted in a washout of a septic joint, a 6-week course of intravenous antibiotics, and a 59-day hospitalization. The patient was discharged without new chronic medical issues, including a lack of new end-organ dysfunction or chronic pain of the joint affected by septic arthritis. Conclusions: This case demonstrates an atypical presentation of gram-positive systemic infection, displaying the complications which may develop with the use of immunomodulators. Because of the potential for severe infection with atypical, insidious presentation, a high index of suspicion should be maintained in all patients receiving these agents. © Journal of Emergency and Critical Care Medicine.","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":"47158549","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}

{"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}