Emergency department initiation of percutaneous cardiopulmonary support for traumatic cardiac tamponade with coagulated pericardial effusion

Cardiac rupture following blunt trauma is associated with a high mortality rate. We present a rescued case of blunt traumatic cardiac tamponade successfully initiated with percutaneous cardiopulmonary support (PCPS) at the emergency department (ED) without pericardiocentesis.A 27-year-old woman was transferred to our hospital after a motor vehicle accident. She presented with profound shock, and the cardiac portion of the focussed assessment of sonography for trauma (FAST) showed almost coagulated pericardial effusion. We considered that the haemodynamic collapse was caused by cardiac tamponade, and we initiated PCPS in the ED. Subsequently, her systemic perfusion was preserved by PCPS, and she was transferred to the operating room safely. A laceration of the right atrium was successfully repaired. In cardiac tamponade, blood accumulation in the pericardium may be localised and the formation of blood clots may cause difficulty with aspiration. The initiation of PCPS afforded time to surgeons prior to definitive surgical repair and enabled the patient's transfer to the operating room securely.This report demonstrated the case of a rare, but successful outcome of resuscitation of a patient with blunt traumatic cardiac rupture with cardiac tamponade. PCPS is considered as an important treatment option in ED for traumatic cardiac tamponade, particularly if the effusion has clotted.     

三种脑卒中筛查量表对急诊疑似卒中患者应用价值的研究

目的 分析ROSIER、FAST、LAPSS三种卒中筛查量表对急诊疑似卒中患者的应用价值.方法 2012-05～ 2012-11共收集223例广州医学院第二附属医院急诊就诊的疑似卒中患者,记录其临床特征,在急诊使用三种卒中筛查量表(ROSIER量表、FAST量表、LAPSS量表)进行评估,根据影像学结果及住院记录明确最终诊断,比较三种卒中量表在急诊室内的应用价值.结果 223例患者中包括脑卒中194例(脑梗死132例、脑出血60例及短暂性脑缺血发作2例),非卒中29例.ROSIER量表灵敏度为76.3％,特异度为65.5％;FAST量表灵敏度为72.7％,特异度为65.5％;LAPSS量表灵敏度为62.4％,特异度为75.9％.ROSIER量表及FAST量表的灵敏度与LAPSS量表比较差异均有统计学意义(P＜0.05).结论 ROSIER、FAST、LAPSS三种量表在急诊室内的应用价值均欠佳,需进一步研究出适用于国内急诊室的卒中筛查量表.     

Ultrasound-guided percutaneous drainage of a traumatic abdominal wall hematoma in the emergency department

BACKGROUND:

Abdominal wall hematoma is due to trauma, coagulation disorders or anticoagulation therapy complications.

METHODS:

In this report we present a case of a 44-year-old female who suffered from blunt abdominal trauma and presented to the emergency department with sharp abdominal pain and ecchymosis. FAST and abdominal computerized tomography (CT) revealed an abdominal wall hematoma. Treatment with an ultrasound-guided percutaneous drainage was performed successfully.

RESULTS:

The patient remained under observation for six hours with serial ultrasound scans, and no signs of hematoma recurrence were present. She was discharged the same day with clinical improvement.

CONCLUSION:

Complete history investigation and clinical examination help to make a correct diagnosis of abdominal wall hematoma, select a prompt treatment, and reduce complications.KEY WORDS: Rectus sheath hematoma, Abdominal wall hematoma, Emergency Department, FAST, Ultrasound guided percutaneous drainage     

Validation of nurse-performed FAST ultrasound

Background

Patients presenting to Emergency Departments (EDs) with abdominal trauma benefit from FAST (Focused Assessment with Sonography in Trauma). Not all doctor members of the trauma team are credentialed in FAST; therefore occasionally no one is available in the hospital to undertake a FAST. Hence, the aim of this study was to determine the accuracy of nurse-performed FAST as a practical alternative where suitably trained doctors are not available.

Methods

This was a prospective study of a convenience sample of patients with multisystem trauma in whom abdominal injury was clinically suspected. Senior nurses trained in FAST performed and reported FAST scans for each patient. Accuracy of nurse-performed FAST was determined by comparing results with computerised tomography (CT) scan or operation report.

Results

242 indicated nurse-performed FAST scans were included in the study. Nurse-performed FAST demonstrated sensitivity of 84.4% (95% CI 72.1-92.2) and specificity of 98.4% (CI 94.9-99.6), a positive predictive value (PPV) of 94.2% (CI 83.1-98.5) and a negative predictive value (NPV) of 95.3% (91.0-97.7). Overall accuracy of nurse-performed FAST for the detection of free fluid was 95.0% (95% CI 91.3-97.3).

Conclusion

This study demonstrates that, in a convenience sample of injured patients, nurse-performed FAST achieved similar accuracy to previously published results of doctor-performed FAST. Future studies with greater patient numbers would be valuable.     

What are the ten new commandments in severe polytrauma management?

This review aims to provide a concise overview of the trauma management evolution in the past decade. 1) Trauma care priorities have incorporated staff protection against infection and early decision making in addition to the conventional ABCDE. 2) Five stratified levels for DAM have replaced the non-specific conventional Plans A & B. 3) CT scanning can be the tunnel to death for the hemodynamically unstable patient. 4) DPL has virtually been replaced by the FAST USG. 5) Direct whole-body MDCT provides rapid imaging diagnosis & expedites the definitive treatment but carries high radiation hazards. 6) The dynamic shock assessment by fluid resuscitation response provides more outcome-specific evaluation than the static blood volume loss model. 7) DCR comprising of permissive hypotension, hemostatic resuscitation & DCS aims to overcome the lethal triad of trauma. Early transfusion of blood components of FFP & platelet concentrates improves the outcome in massive blood transfusion. 8) DCS aims to rectify the deranged physiology and not to fully restore the damaged anatomy. 9) A pre-defined protocol for major pelvic fracture can be life-saving and the novel Pre-PPP (pre-peritoneal pelvic packing) may further reduce mortality coupled with the necessary TCAE. 10) Injury prevention is equally important if not more than the trauma resuscitation & operation.KEY WORDS: Polytrauma, Priorities, DAM, CT, MDCT, DPL, FAST, Fluid resuscitation responder, DCR, DCS, Pre-PPP, Injury preventionPolytrauma management has undergone tremendous evolution in the past decade in the assessment, diagnosis, treatment and team approach algorithms. This article aims to highlight the important changes in a concise manner.     

A systematic review of evidence for the role of inflammatory biomarkers in bipolar patients

Bipolar disorder (BD) is a neuropsychiatric disorder that is characterized by a phasic course of affective episodes interspersed with a euthymic state. Epidemiological, clinical, genetic, post-mortem and preclinical studies have shown that inflammatory reactions and immune modulation play a pivotal role in the pathophysiology of BD. It is conceptualized that biomarkers of inflammation and immune responses should be employed to monitor the disease process in bipolar patients. The objective of this systematic review is to analyse the inflammatory markers involved in human studies and to explore each individual marker for its potential clinical application and summarize evidence regarding their role in BD. A systematic review of human studies to measure inflammatory markers was conducted, and the studies were identified by searching PubMed/MEDLINE, PsycINFO, EMBASE, and Web of Science databases for peer-reviewed journals that were published until September 2015. In this review, we included peripheral markers, genetic, post-mortem and cell studies with inflammatory biomarker analysis in BD. One hundred and two (102) papers met the inclusion criteria. The pro-inflammatory cytokines were elevated and the anti-inflammatory cytokines were reduced in BD patients, particularly during manic and depressive phases when compared to the controls. These changes tend to disappear in euthymia, indicating that inflammation may be associated with acute phases of BD. Even though there are promising findings in this field, further clinical studies using more established detection techniques are needed to clearly show the benefit of using inflammatory markers in the diagnosis, follow-up and prognosis of patients with BD.     

Effects of Yokukansan on behavioral and psychological symptoms of dementia in regular treatment for Alzheimer's disease

Yokukansan (YKS) is used frequently against behavioral and psychological symptoms of dementia (BPSD) together with donepezil in patients with Alzheimer's disease (AD). Here, we investigated the efficacy and safety of YKS in patients with AD in a non-blinded, randomized, parallel-group comparison study. Patients who had at least one symptom score of four or more on the Neuropsychiatric Inventory (NPI) subscales were enrolled in the study. The subjects were randomly assigned to the YKS-treated group (YKS/donepezil combination therapy group) and the non-YKS-treated group (donepezil monotherapy group). TSUMURA Yokukansan (TJ-54, 7.5 g, t.i.d.) was administered in a four-week study treatment period. The subjects were evaluated twice at the start (Week 0) and completion (Week 4) of the study treatment in terms of NPI, Mini-Mental Status Examination (MMSE), Disability Assessment for Dementia (DAD), Zarit Burden Interview, and Self-rating Depression Scale (SDS). The efficacy analysis was performed in 29 patients (YKS-treated group) and 32 patients (non-YKS-treated group). The NPI total score improved significantly more in the YKS-treated group than in the non-YKS-treated group. In the NPI subscales of agitation/aggression and irritability/lability, the YKS-treated group showed significantly greater improvement than the non-YKS-treated group, but no statistically significant improvement was seen with YKS in the other subscales. There were no significant differences between the YKS-treated group and the non-YKS-treated group in MMSE, DAD, Zarit Burden Interview and SDS. No adverse reactions were noted in either group. The results of this study showed that YKS is safe and effective in the treatment of BPSD in AD patients.