Metastatic adenocarcinoma from the lung occurring as occult gastrointestinal bleeding

We believe this is the first reported case of metastatic carcinoma of the lung occurring with occult gastrointestinal bleeding. Most small bowel metastatic tumors of various primaries are asymptomatic and are usually diagnosed at emergency operation. Since the prognosis is generally poor, operative resection should be conservative.     

Spinal cord compression: an oncologic emergency associated with metastatic cancer: evaluation and management for the home health clinician

Spinal cord compression is an oncologic emergency that needs to be identified, evaluated, and treated promptly for favorable patient outcomes. Although there are nonmalignant types of spinal cord compression, this article focuses on patients presenting with metastatic cancer. Home care clinicians should be knowledgeable with current assessment strategies aimed at recognizing this potentially debilitating condition. Using an assessment tool could assist clinicians with early detection of spinal cord compression, which could improve the overall quality of life.     

Malignant Spinal Cord Compression

Malignant spinal cord compression (MSCC) occurs in the setting of primary or metastatic cancer. It is the result of primary tumor invasion into the spinal canal or metastatic spread to the vertebrae resulting in collapse onto the spinal cord or, less commonly, direct metastatic spread into the epidural space or cord. MSCC may lead to progressive and permanent motor and sensory deficits if untreated. Although not life-threatening, MSCC is a true medical emergency that requires early recognition and prompt intervention in order to provide the best chance for clinical recovery. Nurses play a pivotal role in identifying patients at risk, recognizing the symptoms signifying the onset of MSCC, implementing evidence-based strategies, and educating at-risk patients about the manifestations of MSCC and actions they should take. Although these roles are not specific to nurses in radiology or procedural areas, knowledge of MSCC is essential. Understanding MSCC will enhance the nurses’ ability to field questions and clarify misconceptions about this emergency and mitigate procedure-related complications (e.g., positioning, pain).     

Fulminant diabetes due to immune checkpoint inhibitors in the emergency department

Immune checkpoint inhibitors (ICIs) are of growing importance in new cancer therapies, exposing patients to various and potentially severe immune-related adverse events and placing emergency physicians on the front line when they occur. If endocrine toxicity is a well-known complication of ICIs, fulminant diabetes with diabetic ketoacidosis is exceptional. We present a case of fulminant diabetes after only two cycles of pembrolizumab in a 53-year-old man with a history of metastatic lung cancer who presented to our emergency department with coma and acidosis revealing diabetic ketoacidosis. The patient was rehydrated and treated with insulin and recovered quickly. Lung toxicity was also suspected on CT-scan findings. This rare and life-threatening complication that developed unusually early during the treatment course may be challenging in a cancer patient. Therefore, emergency physicians should investigate symptoms in patients treated with checkpoint inhibitors and consider toxicity when they present to the ED with complaints compatible with an immune-related adverse event.     

Emergency abdominal surgery for small bowel perforation secondary to metastatic lung cancer

Emergency surgery for bowel perforation caused by metastases from lung cancer is rare. Two cases of small bowel perforation due to metastasizing lung cancer are reported. Both patients were admitted as a surgical emergency case. One of the two patients presented herein survived and was discharged from the hospital. Perforated small bowel due to metastatic lung cancer is a highly fatal event that occurs in the late phases of the disease. Despite the poor prognosis, early and appropriate therapy will occasionally yield successful surgical palliation. Patients with known lung cancer who develop abdominal complaints should be examined thoroughly and treated quickly.     

Retropharyngeal phlegmon in a hemodialysis patient with Staphylococcus aureus bacteremia

Staphylococcus aureus bacteremia is a frequent occurrence in patients with indwelling catheters. Endocarditis, osteomyelitis, and septic arthritis are common metastatic complications. A hemodialysis patient developed fever, headache, neck pain, sore throat, and dysphagia in the setting of S. aureus bacteremia. Contrast computed tomography scan of the neck revealed a retropharyngeal phlegmon. Recurrent bacteremia led to the identification of the access graft as the infectious source. We present this case to increase awareness among emergency physicians that retropharyngeal infection by S. aureus can arise by hematogenous spread and should be considered in the differential diagnosis of a bacteremic patient with sore throat or neck pain.     

Metastatic epidural spinal cord compression.

OBJECTIVES: To provide an overview on the presentation, diagnosis, and treatment of metastatic epidural spinal cord compression (MESCC). DATA SOURCES: Published articles, book chapters, and research reports. CONCLUSIONS: MESCC is a common oncologic emergency that requires prompt recognition and emergency treatment to relieve pain and preserve neurologic function. The signs and symptoms of MESCC are easily detected and can be integral assessment components of the nursing care of any patient with a solid tumor. IMPLICATIONS FOR NURSING PRACTICE: Nurses can have a dramatic impact on preventing neurologic complications caused by this oncologic metastatic problem. When neurologic compromise is not prevented or reversed, nurses also can provide expert care to patients and families in the rehabilitation phase of MESCC.     

Cancer presentation in the emergency department: a failure of primary care.

Emergency departments are intended to be the location of entry into the health care system for patients with acute problems, such as injuries and myocardial infarctions. In contrast, cancer should optimally be detected during periodic health examinations, either through screening procedures or by early detection from signs and symptoms which prompt a routine visit to a primary care physician. This study was undertaken to describe patients who present to an emergency department with urgent symptoms and signs, are hospitalized, and subsequently diagnosed with cancer (ED group). One hundred twenty-nine patients were retrospectively studied. When compared with patients diagnosed in a primary care setting (tumor registry patients), the ED group was significantly older, more often male, had a significantly lower survival rate, and more frequent metastatic disease at diagnosis (P less than .001). The ED group accounted for 5.3% of the new tumor registry patients for the study years. Only 3.1% of the ED group had no insurance, and 21% reported no personal physician. Strategies are needed for patients and physicians to reduce the number of late-diagnosed cancer cases presenting in emergency departments.     

急诊医学研究新视角

急诊医学的研究热点与国家医疗卫生政策密切相关,具有明显的社会学特性,涉及如急诊医学运行模式的研究、急诊科拥挤现象的研究、如何进行医学知识转化和急诊医学临床决策、危重症绿色通道研究、弱势群体的急诊处理特点研究等新研究领域,而不仅仅局限于传统的急诊医学研究方向:急危重症评估和脏器功能支持.新的研究热点不断拓展,极大地丰富了现代急诊医学理论体系.     

Treatment of oncologic emergencies

Most oncologic emergencies can be classified as metabolic, hematologic, structural, or side effects from chemotherapy agents. Tumor lysis syndrome is a metabolic emergency that presents as severe electrolyte abnormalities. The condition is treated with allopurinol or urate oxidase to lower uric acid levels. Hypercalcemia of malignancy is treated with aggressive rehydration, furosemide, and intravenous bisphosphonates. Syndrome of inappropriate antidiuretic hormone should be suspected if a patient with cancer presents with normovolemic hyponatremia. This metabolic condition usually is treated with fluid restriction and furosemide. Febrile neutropenia is a hematologic emergency that usually requires inpatient therapy with broad-spectrum antibiotics, although outpatient therapy may be appropriate for low-risk patients. Hyperviscosity syndrome usually is associated with Waldenstr?m's macroglobulinemia, which is treated with plasmapheresis and chemotherapy. Structural oncologic emergencies are caused by direct compression of nontumor structures or by metastatic disease. Superior vena cava syndrome presents as neck or facial swelling and development of collateral venous circulation. Treatment options include chemotherapy, radiation, and intravenous stenting. Epidural spinal cord compression can be treated with dexamethasone, radiation, or surgery. Malignant pericardial effusion, which often is undiagnosed in cancer patients, can be treated with pericardiocentesis or a pericardial window procedure.     

Current possibilities of cytological assay in the study of pleural and peritoneal exudates

Serous exudates were studied by immunoperoxidase and immunofluorescence immunocytochemical assays and by laser flow cytofluorimetry. The current high-tech techniques detect sparse tumor complexes in the exudates at the early metastatic stages, which are undetectable by the routine cytological assay, and also reduce the hyperdiagnosis of the tumor process. The use of a set of immunocytochemical markers can specify the source of metastatic spread when the primary tumor focus is not found. Fluorescence immunocytochemistry of the exudates has been shown to be highly effective and rapid during emergency intraoperative studies to clarify the extent of the tumor process.     

地震期间急诊救治糖尿病酮症酸中毒伴高渗性昏迷1例

患者,男,19岁,身高175cm,体重100kg,系甘孜人。在雅安芦山"4.20"地震期间,因长途坐车,进食少、多次大量饮用冰糖雪梨等含糖高的饮料后,出现疲倦、四肢无力,自行休息,约4h后,上述症状无缓解并出现口渴、厌食、不能自行行走,家人带其至一家私人诊所治疗,给予其"生脉口服液"治疗,效差,患者晕倒。我院120接诊,给氧、建立     

Mental nerve neuropathy: case report and review

Mental nerve neuropathy (MNN) or "numb chin syndrome" is a rare neurologic symptom most often associated with malignancy. Patients typically develop paresthesia or numbness localized to the chin and lower lip and will often seek care at their local emergency department. Pain and expansion of the lower jaw may also be present. We report a case of MNN associated with a metastatic lesion in the mandible. The purpose of this article is to highlight the importance of recognizing MNN, a potentially life-threatening symptom of metastatic carcinoma, and enable clinicians to properly diagnose MNN, which may mimic other conditions that affect the mandible.     

Dying and defibrillation: a shocking experience

Palliative Care physicians are frequently involved in the care of patients with significant comorbidity and often have to take coexisting conditions into account when treating patients. An example of an area in which this is particularly relevant and will undoubtedly increase is presented with the case report of a patient with terminal metastatic lung carcinoma and an Implantable Cardioverter Defibrillator (ICD) in place. The role of the ICD in preventing the patient from dying comfortably is discussed, as are means of deactivating the device. We conclude that patients with ICDs and terminal disease should have the issue of deactivation addressed at the earliest possible opportunity as practical difficulties may arise in the emergency setting, especially in the nonhospital environment.     

Liver metastasis presenting as pneumoperitoneum

A 63-year-old man presented to the emergency department with sudden-onset abdominal pain. Chest radiography demonstrated pneumoperitoneum. At surgery, the source was found to be a ruptured hepatic abscess. Cultures grew Clostridium perfringens, and biopsies confirmed metastasis of a previously resected pancreatic cancer. We document this rare cause of pneumoperitoneum and briefly review the literature on liver abscess as it relates to metastatic cancer.     

Critical pancreatitis management associated with hypertriglyceridemia in pregnancy in emergency service

Because of the variable clinical features of acute pancreatitis, it is difficult to make a differential diagnosis in patients presenting with abdominal pain in emergency departments. Acute pancreatitis due to severe hypertriglyceridemia during pregnancy is rare but due to the increased risk of maternal and fetal mortality, diagnosis and treatment options should be known and should be performed in the emergency department, which is the first admission site.In this case report, we present a 20-year-old woman with 19 weeks pregnant who presented to the emergency department with abdominal pain and whose biochemistry parameters were high enough to give lipemic stimulation was hospitalized in the emergency ıntensıve care unit (EICU) in the emergency department and lipid apheresis treatment was planned successfully. Lipid apheresis treatment in patients with resistant hypertriglyceridemia in the emergency department should become an easy, safe and effective option with the use of an emergency intensive care unit.     

医院灾害应急准备的国内外文献分析

目的系统检索报告／介绍应对国内外重大灾害的医院应急准备相关文献并加以总结与分析，为我国医院建立应对突发事件的应急准备提供参考。方法系统检索MEDLINE（1950～2008．6）、CNKI（1980～2008．6）和相关网站，对符合纳入标准的文献的主要结果进行描述性分析。结果共纳入85篇文献，其研究类型以专家意见和现况调查居多，分别占43．53％和29．41％。应对突发事件的医院应急准备是一个减灾、准备、反应和恢复的动态过程。应急准备可考虑以下内容：短期内成批接纳伤员能力、防灾减灾预案、合作与协调、培训与演习、人力资源、物资设备、实验室能力、伤员分检分类、诊断和治疗、消毒、经费保障、员工安全、后勤保障和心理支持等。医院应急准备可采用调查、清单或专用评估工具进行评价。结论医院应急准备是灾害救援的重要环节，医院应针对不同灾害和本地实情及各类灾害风险作好切实可行的灾害救援应急预案。     

Infectious diarrhea

Patients presenting to the emergency department with diarrhea should be evaluated for infectious causes. Information obtained from the history and physical examination should be used in deciding whether symptomatic treatment alone is sufficient or whether the patient's stool should be examined for pathogens. Antiperistaltic agents should be used only in selected patients, usually after the results of stool cultures are known to be negative. Antibiotic administration should be based on results of stool cultures and examination for parasites. Finally, the emergency physician should be familiar with the special situations of traveler's diarrhea, food-borne illness, and sexually transmitted enteric disease.     

Central neurogenic hyperventilation secondary to suspected metastatic renal cell carcinoma

Central neurogenic hyperventilation (CNH) is a neurogenic disorder rarely described within Emergency Medicine literature. CNH is a primary cause of hyperventilation, most commonly due to primary central nervous system neoplasms. Patient presentation varies based on the underlying cause, and may present with a sole chief complaint of dyspnea. We present a case of an adult male with a history of deep vein thrombosis, anticoagulated on apixaban, and extensively metastatic renal cell carcinoma who presented with a two-week history of dyspnea. Evaluation in the emergency department showed a primary respiratory alkalosis with a compensatory metabolic acidosis. Diagnostic work-up failed to reveal a cardiac, pulmonary, metabolic, or toxic cause. During the emergency department course, the patient became dysarthric and altered, at which point, computed tomography scan of the head revealed a pontine hemorrhage. The hemorrhage was stabilized with prothrombin complex concentrate, but the patient's dyspnea and mental status deteriorated throughout the course of his hospitalization. While the cause of the patient's hemorrhage was not elucidated, given the patient's widely metastatic disease, it was presumed to be secondary to metastasis. Our case highlights both a unique cause of a rare disorder of hyperventilation, and a diagnostic challenge to the emergency medicine provider. It is important to consider central causes of hyperventilation in patients with dyspnea and neurologic symptoms.     

急诊外科创伤患者死亡原因分析

目的:急诊外科为各类创伤患者的首诊科室,探讨如何提高急诊外科抢救成功率,减少外伤死亡.方法:回顾性分析我院急诊外科34例死亡病例.结果:青壮年男性为急诊外科死亡高危人群,交通伤是急诊外科死亡第一致病病因.死亡主要原因是颅脑损伤和创伤失血性休克.结论:应加强院前急救与院内急诊外科的联系,进一步普及创伤现场急救的知识,急诊外科医师应掌握高级创伤生命支持(ATLS).创伤失血性休克患者入抢救室之时就应该是准备输血的开始.急诊外科危重患者的抢救必须争分夺秒.