Chii-Hwa Chern

D-dimer in patients with suspected acute mesenteric ischemia.

OBJECTIVESnThe aims of this study were to assess the diagnostic value of D-dimer in patients with suspected acute mesenteric ischemia (AMI) and to evaluate the correlation between D-dimer levels and the severity of bowel necrosis.nnnMETHODSnA prospective, noninterventional study of 67 patients with clinical suspicion of AMI was performed. Measurement of D-dimer levels was performed using a latex turbidimetric method.nnnRESULTSnAcute mesenteric ischemia was diagnosed in 23 patients (34.3%) and non-AMI in 44 patients (65.7%). Median D-dimer levels on admission were 6.24 microg fibrinogen equivalent units (FEU)/mL (range, 0.96-53.48 microg FEU/mL) in patients with AMI and 3.45 microg FEU/mL (range, 0.50-44.69 microg FEU/mL) in non-AMI patients (P = .064). D-dimer had poor discriminative value to differentiate the presence from the absence of AMI with an area under the receiver operating characteristic curve of 0.64 (95% confidence interval, 0.50-0.78). A serum D-dimer cutoff value of 1.0 microg FEU/mL had a sensitivity of 96%, a specificity of 18%, a positive likelihood ratio of 1.17, and a negative likelihood ratio of 0.24. Among patients with AMI verified at operation, 8 had resectable bowl necrosis and 9 had unresectable bowel necrosis. There was no difference in serum D-dimer levels between resectable and unresectable bowel necrosis (P = .665).nnnCONCLUSIONSnDetection of serum D-dimer could not help to differentiate patient with AMI from those with non-AMI. We did not find a correlation between serum D-dimer levels and the severity of AMI. However, measurement of D-dimer levels can be of value for a small decrease in the likelihood of AMI, when the result is low.

Is ward experience in resuscitation effort related to the prognosis of unexpected cardiac arrest

Background: The aim of this study was to investigate the outcome of patients of unexpected cardiac arrest initially resuscitated by first responders with dissimilar experiences under the support of cardiac arrest team (CAT). Methods: All unexpected cardiac arrest patients receiving in‐hospital resuscitation with the activation of CAT in a tertiary‐care teaching hospital over a 12‐month period were recorded according to the Utstein criteria. We prospectively recorded various factors at resuscitation and retrospectively evaluated the outcome. Outcome measures included return of spontaneous circulation (ROSC), survival longer than 24 hours, and survival to discharge. Results: Altogether, 76 emergency calls were registered, and among these, 44 calls (58%) were cardiac arrests, including 8 ventricular tachycardia/fibrillation, 15 pulseless electrical activity, and 21 asystole. The rate of ROSC was 61%, the rate of survival longer than 24 hours was 37%, and the rate of survival to discharge was 18%. The response time of our CAT was 271 seconds (4 minutes and 31 seconds) on average. The patients who collapsed in the wards experienced in resuscitation effort received higher rates of appropriate basic and advanced cardiac life support interventions before CAT arrival (79% vs. 44%; p = 0.019), had an increased chance of ROSC (75% vs. 38%; p = 0.014), survival longer than 24 hours (54% vs. 13%; p = 0.007), and survival to discharge (29% vs. 0%; p = 0.036). Conclusion: Hospital wards with more than 5 cardiac arrests per year have a better patient survival rate than those with fewer arrests. This is despite all ward staff receiving the same level of training.

Diagnosis of unrecognized primary overt hypothyroidism in the ED

OBJECTIVEnThe aims of the study were to evaluate the incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the emergency department (ED) and to assess how previously undiagnosed hypothyroidism presents.nnnMETHODSnFrom July 1, 2002 to June 30, 2006, 56 adult patients were enrolled for further analysis.nnnRESULTSnThe incidence of newly diagnosed primary overt hypothyroidism among adults admitted through the ED is 0.1%. The mean age of the patients was 75.8 ± 12.8 years (range, 27-98 years). Most of our patients presented in the winter. Individual symptoms and signs were not sensitive. Drugs (13xa0patients, 23%), nongoitrogenous autoimmune thyroiditis (12 patients, 21%), and previous surgery or irradiation related (11 patients, 20%) are frequent causes of unrecognized hypothyroidism in this iodine-replete region. Only 21% of patients were admitted with a correct initial impression. Half of myxedema coma patients were missed during the initial ED stay. Thirty-three patients (59%) had cardiomegaly on chest x-ray receiving further echocardiography examination. Pericardial effusion was found in 18xa0patients. Of these, 7 patients had moderate to large pericardial effusion, but none had cardiac tamponade. Only 6 patients have depressed left ventricular ejection fraction (<40%).nnnCONCLUSIONSnThe diagnosis of hypothyroidism is often missed during the ED evaluation of patients at risk for this uncommon disease. Hypothyroidism should always be considered in patients who present with nonspecific symptoms suggestive of the disease, including weakness, cold intolerance, and alterations in mental status, and receive drugs impairing thyroid function or treatment of advanced head and neck cancer. In addition, patients with stable chronic heart failure or unexplained pericardial effusion warrant serum thyroid testing.

Expression of the triggering receptor expressed on myeloid cells‐1 mRNA in a heterogeneous infected population

This study is to investigate the clinical utility of detection of peripheral blood triggering receptor expressed on myeloid cells (TREM)‐1 mRNA as an early indicator of sepsis among critically ill patients and to compare the results of TREM‐1 with those of C‐reactive protein (CRP). A prospective, non‐interventional study of 127 patients with at least two criteria of the systemic inflammatory response (SIRS) was performed. TREM‐1 was assessed by real‐time quantitative reverse transcription‐polymerase chain reaction.

Atrioventricular conduction abnormality and hyperchloremic metabolic acidosis in toluene sniffing

Toluene is an aromatic hydrocarbon with widespread industrial use as an organic solvent. As a result of the euphoric effect and availability of these substances, inhalation of toluene-based products is popular among young adults and children. Chronic or acute exposure is known to cause acid-base and electrolyte disorders, and to be toxic to the nervous and hematopoietic systems. We report a 38-year-old man who suffered from general muscular weakness of all extremities after toluene sniffing, which was complicated with hypokalemic paralysis, atrioventricular conduction abnormality, and normal anion gap hyperchloremic metabolic acidosis. Renal function, serum potassium and acid-base status normalized within 3 days after aggressive potassium chloride and intravenous fluid replacement. Electrocardiography showed regression of first-degree atrioventricular block. Exposure to toluene can lead to cardiac arrhythmias and sudden sniffing death syndrome. Tachyarrhythmia is the classical manifestation of toluene cardiotoxicity. Atrioventricular conduction abnormalities have been rarely mentioned in the literature. Knowledge of the toxicology and medical complications associated with toluene sniffing is essential for clinical management of these patients.

A rare case of massive retroperitoneal hemorrhage after bone marrow aspiration alone

The use of dapsone is increasing even though overdose is rarely reported and physicians must be aware of its toxicity and management. Mortality can occur due to methemoglobinemia and hemolytic anemia. Although activated charcoal and methylene blue are recommended, the use of hemodialysis is reported only in few studies. Literature on the kinetic profile indicates that 50% to 80% of dapsone is protein bound and indicates a possibility to dialyze the unbound form. This study describes a case of deliberate severe dapsone overdose with cyanosis, methemoglobinemia, and hemolytic anemia, which improved after repetitive hemodialysis.

Cerebral dural arteriovenous fistulas presenting as pulsatile tinnitus

A 46-year-old man presented to our emergency department with right-sided pulsatile tinnitus, progressively increasing over a 1-year period. Blurred vision, headache and gait disturbance were also noted in the previous few weeks. He had an unremarkable medical history. The neurological examination and otoscopic findings were essentially normal, but a right retroauricular bruit was heard on auscultation of the head. Brain magnetic resonance imaging/magnetic resonance angiography (MRI/ MRA) showed cerebral dural arteriovenous fistulas (CDAVF) of both transverse-sigmoid sinuses (Fig. 1). Pulsatile tinnitus usually has a vascular origin most commonly a CDAVF. A retroauricular bruit is a pathognomonic clinical sign. CDAVF comprise 10–15% of all intracranial arteriovenous abnormalities and most often involve the dura surrounding the sigmoid and transverse sinuses. Typically, CDAVF are acquired after trauma, surgeryordural sinus thrombosis. InRaupp’s report, themean diagnostic delay was 17.9 months reflecting unfamiliarity with the clinical diagnosis. Failure or delay in the diagnosis of CDAVF may have such catastrophic consequences as intracranial haemorrhage or venous hypertension. For patients with objective pulsatile tinnitus, a radiologic evaluation for vascular abnormalities should be carried out. MRI/MRA is far superior to X-ray computed tomography (CT) scanning in detecting CDAVF. Selective contrast angiography may be needed if non-invasive techniques are negative to clarify abnormal findings, or to guide treatment. Treatment options include stereotactic radiation therapy, endovascular intervention, surgical isolation or resection or a combination of these depending on fistula location and the pattern of venous drainage.

Press through package mis‐swallowing

A press through package (PTP) is commonly used as a package for drugs and also being seen increasingly in cases of foreign body in the digestive tract. We presented three cases of inadvertent PTP ingestion with a variety of clinical presentations. Although commonly considered to be small and soft to cause bowel damage, a PTP tends to be caught and poses potential risk for perforation of the bowel because of its sharp edges. The PTP material is thought to be difficult to detect on plain abdominal roentgenography due to its radiolucency. However, air trapped in the PTP makes the drug tablet possibly visible on the radiograph. All of the three cases were diagnosed with correct interpretation of these special radiographic findings, even without the recall of accidental swallowing of the tablet. A PTP in the oesophagus and stomach should be tried to be removed, while computerised tomography and early laparotomy should be considered when it passes through the pyloric ring and the patient develops symptoms. An effort to prevent the PTP swallowing should be an essential part in our everyday practice, especially for the elderly patients.

Improved survival outcome with continuous chest compressions with ventilation compared to 5:1 compressions-to-ventilations mechanical cardiopulmonary resuscitation in out-of-hospital cardiac arrest.

Background: Fewer pauses and better chest compression quality are thought to improve overall survival following cardiac arrest. This study aimed to measure the outcomes of adult nontraumatic out‐of‐hospital cardiac arrests (OHCAs) treated with 5:1 compressions‐to‐ventilations (Thumper 1007) or continuous chest compressions with ventilation (Thumper 1008 CCV) mechanical cardiopulmonary resuscitation (CPR) within a specified period of time. Methods: A retrospective observational cohort study of 515 adults with OHCA was conducted at the emergency department of an urban tertiary hospital. There were 307 patients in the Thumper 1007 phase (January 2008 to December 2009) and 208 patients in the Thumper 1008 CCV phase (January 2010 to May 2011). Return of spontaneous circulation (ROSC) and survival to hospital discharge were the primary outcome measures. Results: Patients in the Thumper 1007 and Thumper 1008 CCV phases had comparable results with the following exceptions: less hypertension (42.4% vs. 62.0%), cerebrovascular accidents (11.4% vs. 25.0%), and faster emergency medical service response time intervals (mean, 3.7 vs. 4.5 minutes) with the Thumper 1007. The average ambulance transport time was 6.1 minutes in both phases. The rates of ROSC [35.1% vs. 23.5%; adjusted odds ratio (OR), 1.616; 95% confidence interval (CI), 1.073–2.432] and survival to hospital discharge (10.1% vs. 4.2%; adjusted OR 2.431; 95% CI, 1.154–5.120) were significantly higher with the Thumper 1008 CCV than with the Thumper 1007. Favorable neurologic outcome upon discharge, defined as cerebral performance category scores of 1 (good performance) or 2 (moderate disability), was not significantly different between the two phases [1.6% (5/307) vs. 1.9% (4/208); p = 0.802]. The Thumper 1008 CCV provided significantly faster average chest compression rates and shorter no‐chest compression intervals than the Thumper 1007 after activation. Conclusion: In an emergency department with short ambulance transport times, continuous chest compressions with ventilation through mechanical CPR showed improved outcomes, including ROSC and survival to hospital discharge, in an adult with OHCA. However, there are a variety of confounding influences that may affect the validity of conclusions that have been drawn.

Descending necrotising mediastinitis: a report of misdiagnosis as thoracic aortic dissection

Descending necrotising mediastinitis is an uncommon disease in the emergency department. Early recognition is important for a good prognosis for this fatal condition. This report describes a case of a healthy 79 year old woman who was seen in the urgent care centre with the initial presentation of chest pain. Misdiagnosis was made because of the mis-reading of a flap-like artefact over the ascending aorta and difficulty interpreting subtle change of mediastinal soft tissue infiltration. The patient was then treated as dissecting aneurysm over ascending aorta until her condition deteriorated. Although aggressive treatment comprising thoracotomy, cervical incision and drainage, and antibiotics were begun, the response was poor. Emergency physicians should be familiar with this rare but highly lethal disease. Correlation should be made in a patient complaining about chest pain, especially combined with fever, sore throat, dysphagia, or neck swelling.