Scurvy identified in the emergency department: a case report

Scurvy, caused by a lack of Vitamin C in the diet, is thought to occur only sporadically in developed countries. The signs and symptoms are diverse but generally follow a predictable progression most striking for their hemorrhagic component, particularly of the skin, gums, and joints. We report a case of scurvy in an elderly, alcoholic woman. The diagnosis was contemplated based on dermatologic findings and a dietary history. All symptoms resolved within 10 days of oral ascorbic acid supplementation. Patients most at risk for developing scurvy include food faddists, the isolated elderly, and the mentally ill.     

急诊脓毒症病死率评分在急诊脓毒症患者中的应用

目的 验证急诊脓毒症病死率评分(mortality in emergency department sepsis score,MEDS)对于急诊脓毒症患者病情评估的应用价值,并将其对患者28 d病死率的预测效果进行比较。方法 对2009年9月至2010年9月首都医科大学附属北京朝阳医院急诊抢救室救治的613例脓毒症患者进行前瞻性研究。记录患者的证急诊脓毒症病死率评分(MEDS)、急性生理学与慢性健康情况评价系统Ⅱ（acute physiology and chronic health evaluation,APACHEⅡ）、简化急性生理学评分Ⅱ（simplified acute physiology score,SAPSⅡ）和改良早期预警评分(modified early warning score,MEWS)。随访28 d转归。根据患者MEDS评分分值将死亡风险分级：极低危险组(0 ～4分)、低度危险组（5～7分）、中度危险组（8～12分）、高度危险组（13 ～ 15分）、极高危险组（大于15分）,各组间实际病死率采用X2检验比较。再对生存组和死亡组进行比较,通过logistic 回归分析确定预测死亡的独立因素,应用受试者工作特征曲线（ROC曲线）比较MEDS与APACHEⅡ,SAPSⅡ和MEWS评分对预后的预测能力。结果 失访10例,完整记录603例。MEDS评分患者各组实际病死率分别为0％,7.7％,18.5％,46.7％,63％,各组间实际病死率有显著区别。生存组（440例）与死亡组（163例）之间年龄和四种评分差异均具有统计学意义(P＜0.01)。MEDS,APACHEⅡ,SAPSⅡ、MEWS评分均是预测死亡的独立因素,ROC曲线下的面积(AUC)分别为0.767,0.743,0.741和0.636。结论 MEDS评分可以对脓毒症患者死亡风险进行分级,在患者28 d病死率方面有较好的预测能力,适用于急诊脓毒症患者。     

Lung cancer in the emergency department

According to the World Health Organization lung cancer was the leading cause of cancer deaths in 2008. Patients with lung cancer present frequently to the emergency department. This article will outline Non-Small Cell Lung Cancer (NSCLC), patient presentation, and how to care for the patient with lung cancer in the emergency department (ED).     

Retrospective denial of emergency department payments is inappropriate

Third-party payers typically use patients’ discharge diagnoses to determine “appropriate” Emergency Department (ED) usage. This analysis compared the resource intensity involved in ED evaluation for “inappropriate” and all other ED visits. In this retrospective database review, 11 discharge diagnoses (DX11) (chronic nasopharyngitis; chronic sinusitis; chronic pharyngitis; rhinitis; constipation; head cold; hemorrhoids; toothache; flu; headache; and tension headache) were identified by a third party payor as being “inappropriate” for ED evaluation. The chief complaints of all patients seen in 1994 and 1995 with one of the DX11 were identified along with their E & M billing level, ED length of stay (LOS), and the frequency of consultation. In this urban, university trauma center, 1994 and 1995 visits totaled 120,402. Eighty-two different chief complaints were associated with a final diagnosis of DX11; 79% of all ED patients presented with one of the chief complaints (AllCC). Four percent of patients with DX11 were admitted, and the AllCC group had comparable resource utilization to the entire ED population. Patients’ presenting complaints are incapable of predicting diagnosis or disposition. Retrospective denial of payment by discharge diagnosis is inappropriate.     

Attributes of cancer patients admitted to the emergency department in one year

BACKGROUND:

Cancer patients frequently visit the emergency department (ED) with various symptoms of cancer. The purpose of this study was to determine the clinical characteristics and 1-year survival rate of cancer patients in the ED of a university hospital.

METHODS:

We conducted a retrospective review of 408 cancer patients who visited the ED between January 2011 and December 2011. Patient information on demographics, chief complaints, findings, and survival was gathered from the hospital registry and corresponding health administration.

RESULTS:

The study included 240 (58.8%) males and 168 (41.2%) females with a median age of 57.9 years (range 19–87). Regarding cancer staging, 266 patients (65.3%) had metastatic disease and 142 (34.7%) had local and loco-regional disease. The hospitalization rate was 59.6%. The most common symptoms were shortness of breath (23.2%), pain (17.8%), fever (14.2%), and nausea/vomiting (14.4%). The most common cancer sites were the lung (32.5%), gastrointestinal system (25.4%), and breast (9.3%). The initial evaluation determined progressive disease (42.4%), chemotherapy effects (20.7%), infections (17.2%), radiotherapy effects (4.7%), extravasation (1.8%), anemia (1.4%), and unknown (11.3%). During follow up, 191 (46.8%) patients died after admission to the ED. The 1-year overall survival of all patients was 7.3 months.

CONCLUSIONS:

Symptom management in cancer patients is a complex multifaceted concern for the emergency physician. Because of the increasing prevalence of cancer patients, emergency physicians should develop consensus algorithms in collaboration with the relevant disciplines to manage the commonly encountered problems.KEY WORDS: Cancer, Oncology, Emergency department, Survival     

Bench-to-bedside review: Resuscitation in the emergency department

Over the past decade the practice of acute resuscitation and its monitoring have undergone significant changes. Utilization of noninvasive mechanical ventilation, goal-directed therapy, restricted fluid volume, blood transfusion and minimally invasive technology for monitoring tissue oxygenation have changed the practice of acute resuscitation. Early diagnosis and definitive treatment of the underlying cause of shock remains the mainstay for survival after successful resuscitation. Patient-centered outcome end-points, in addition to survival, are being utilized to appraise the effectiveness of treatment. Application of medical ethics to the ever changing practice of acute resuscitation has also become a societal expectation.     

Bench-to-bedside review: Resuscitation in the emergency department

Over the past decade the practice of acute resuscitation and its monitoring have undergone significant changes. Utilization of noninvasive mechanical ventilation, goal-directed therapy, restricted fluid volume, blood transfusion and minimally invasive technology for monitoring tissue oxygenation have changed the practice of acute resuscitation. Early diagnosis and definitive treatment of the underlying cause of shock remains the mainstay for survival after successful resuscitation. Patient-centered outcome end-points, in addition to survival, are being utilized to appraise the effectiveness of treatment. Application of medical ethics to the ever changing practice of acute resuscitation has also become a societal expectation.     

Bench-to-bedside review: Outcome predictions for critically ill patients in the emergency department

The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. Development and implementation of physiologic scoring systems specific to this setting is potentially useful in the early recognition and prognostication of illness severity. A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED.     

急诊科老年患者谵妄评估工具的研究进展

对急诊科老年患者谵妄评估工具进行综述,并分析影响急诊科老年患者谵妄评估量表应用的障碍因素,为动态监测患者的谵妄进展,制订个性化的谵妄评估方案提供借鉴。     

Elderly patients in the emergency department.

Emergency department nursing care of the older individual requires a specific knowledge base to ensure optimal outcomes. Health-care resource utilization specific to elderly patients in the emergency department and selected common health problems that bring older people to the emergency department are described. Distinctions between normal age-related changes and disease signs and symptoms are explained to provide emergency department nurses with the requisite information to care for the elderly appropriately.     

Usefulness of severity scores in patients with suspected infection in the emergency department: a systematic review

Background

Score systems for severity of illness and organ dysfunction have been validated and used as tools to predict the risk of death in intensive care unit (ICU) patients, but their usefulness in patients with suspected infection in the emergency department (ED) or hospital ward is unclear.

Objectives

The objective of this systematic review was to establish the accuracy of score systems in the prediction of mortality in patients with suspected infection in hospital settings compared to the ICU.

Methods

Three researchers independently performed a systematic search and a review of related articles and their references using the PubMed database. The articles were selected by consensus, based on previously defined inclusion and exclusion criteria.

Results

In total, 21 studies were included, 19 of which were carried out in the ED. The researchers found that the operative characteristics to evaluate the accuracy (calibration and discrimination) of the different scores were insufficiently assessed in most studies. Only two studies evaluated the calibration, using the Hosmer-Lemeshow goodness-of-fit test, and less than half of the studies evaluated the discrimination, using the area under the receiver operator characteristics curve.

Conclusions

The reviewed literature did not provide enough information to assess the accuracy of the prognostic models in patients with suspected infection admitted to the ED and hospital ward. Some reports suggest a better accuracy with new scores like the MEDS (Mortality in Emergency Department Sepsis score), but the results are not consistent.     

Retrospective analysis of forensic cases in refugees admitted to emergency department

IntroductionThe aim of this study was to compare the distribution and frequency of forensic medical events in a refugee group with that of the general population, and thus, extrapolate the problems encountered in the immigrant population.MethodsThose cases admitted to the emergency department (ED) for any reason that required a forensic examination between January 2016 and June 2018 were investigated retrospectively.ResultsA total of 310 refugees were admitted to the ED for forensic medical events. The most common nations of origin of the refugees were Iraq (n = 167), Syria (n = 65), and Afghanistan (n = 28). The median age of the refugees was 24 years old (interquartile range = 17–33). With regard to forensics, the most common reasons for the refugees to present to the ED were motor vehicle accidents 27.4%, assaults 25.8%, employment and industrial accidents 16.1%, and suicide attempts 10.3%. Other than suicide attempts, all of the forensic presentations were more common in the males. The outcomes of the refugee group were as follows: 92.3% were discharged, 5.8% were admitted to the hospital, 1% were admitted to the intensive care unit (ICU), and 1% were transferred. Suicide attempts were the most common reasons for the ICU admissions, while the most common reasons for the hospital admissions were orthopedic injuries.ConclusionIn general, the forensic event frequency in the refugee group was lower (p = 0.001); however, this was a single center study, and there could have been unrecorded cases due to an inability to access healthcare assistance, so these results may not be reliable.     

Extubating trauma patients in the emergency department

BackgroundTrauma patients often require endotracheal intubation for urgent or emergent airway protection or to allow expeditious imaging when they cannot cooperate with the needed evaluation. These patients may occasionally be extubated in the emergency department (ED) when the trauma workup is negative for consequential injuries and eventually discharged from the ED. The timing and safety of discharging these patients is unclear.ObjectiveThe objective of this study was to identify the adverse outcomes and evaluate the safety of extubating trauma patients who are clinically well following evaluation in the ED.MethodsRecords of trauma patients who were intubated and then extubated in the ED at a single level 1 trauma referral center during the 4-year study period (Jan 2014 – Dec 2017) were retrospectively abstracted. The primary outcome was the incidence of a post-extubation complication, including desaturation, emesis, aspiration, need for sedative administration, or unplanned reintubation. Additional outcome measures included final disposition, duration of observation following extubation, ED length of stay and return to the hospital within 72 h.ResultsThere were 59 eligible patients identified over the study period, of whom 95% presented following blunt trauma. One patient (1.7%; 95% confidence interval 0–9) required unplanned reintubation and developed aspiration pneumonia following re-extubation. Forty-two (71%) of the patients were discharged from the ED following extubation and a period of post-extubation observation with a mean of 5.8 h (0.6–16.7 h). None of the patients who were discharged returned to the ED within 72 h with complications related to extubation (0%; 95% confidence interval 0–6%).ConclusionsPatients presenting to the ED with possible acute traumatic injuries who are intubated and then extubated after trauma evaluation and resolution of the indication for intubation appear to have a low incidence of complication or return visit when discharged from the ED after a brief period of observation. Specific extubation and discharge criteria should be developed to ensure the safety of this practice. Further validation is required in the form of larger and prospective studies.     

急诊介入治疗鼻咽癌出血11例护理体会

目的：研究影响急诊介入手术抢救成功率的护理因素。方法：对11例鼻腔大出血的急诊患者介入手术期护理作回顾性分析。结果：11例急诊鼻咽癌出血介入手术患者，均抢救成功。结论：开展急救护理，密切配合手术医生，把握病情变化，可有效地提高介入手术抢救成功率。     

急诊介入治疗鼻咽癌出血11例护理体会

目的:研究影响急诊介入手术抢救成功率的护理因素。方法:对11例鼻腔大出血的急诊患者介入手术期护理作回顾性分析。结果:11例急诊鼻咽癌出血介入手术患者,均抢救成功。结论:开展急救护理,密切配合手术医生,把握病情变化,可有效地提高介入手术抢救成功率。     

急诊介入治疗鼻咽癌出血11例护理体会

目的研究影响急诊介入手术抢救成功率的护理因素.方法对11例鼻腔大出血的急诊患者介入手术期护理作回顾性分析.结果¨例急诊鼻咽癌出血介入手术患者,均抢救成功.结论开展急救护理,密切配合手术医生,把握病情变化,可有效地提高介入手术抢救成功率.