Yu-Jang Su

The evaluation of microbiology and prognosis of fournier’s gangrene in past five years

ObjectivesFournier’s gangrene (FG) is an devastating disease that affects the perineum and genitourinary region, and is commonly a result of poly-microbial infection. This study is aimed to determine the correlation between micrology and prognosis of FG in the past five years.MethodsThis study was a retrospective cohort study that was designed to study the trends in micrology and prognosis of FG. From the PubMed database, articles published in the recent 5xa0years (from Jan1st, 2009 to Dec 31st, 2013) were reviewed. A total of 19 articles (each with nu2009>u200930 and with thorough data descriptions in the topic of Fourniers gangrene), were enrolled in this study. The consolidated data was further analyzed by commercial statistical software (SPSS for Windows).ResultsThe twenty-two studies have covered FG cases from year 1981 to 2011, with a mean duration of 9.2xa0years. The total number of cases is 4,365. Majority of the cases are male (84.1%). The mean age and mortality rate is 51.8u2009±u20095xa0years old and 11.1u2009±u20098.9%, respectivly. The most commonly found pathogen is poly-microbial organism (54%), followed by Escherichia coli (46.6%) and Streptococcus (36.8%). The major risk factors are diabetes (43.7%), Body mass index ofu2009>u200930 (40.7%), and hypertension (38.1%). Mortality rate in older patient group (ageu2009>u200951.8xa0years old) is significantly higher than those of the younger group (22% vs. 5.5%, pu2009=u20090.0001).ConclusionsOlder patients with genital or perineal pain should be examined for crepitus dermis. When a patient is diagnosed with FG, swift consultation with surgeons and administration of broad-spectrum antibiotics are required in order to save the patient’s live.

Acute aortic dissection (AAD) in the elderly

AAD is a relatively uncommon yet catastrophic disease. Though the relationship between AAD and age has been discussed in several previous studies, many facets of the relationship between AAD and the elderly still remain unclear. From a retrospective review of charts from January 1, 2005 to December 31, 2010, we collected data of 132 spontaneous AAD cases in a medical center in Taiwan, 83 of which were enrolled in our study. We divided patients into two groups: one above 65 years old (elderly), and a second, non-elderly group. Data collected for statistical analysis included: clinical manifestations on arrival, time of onset, type of AAD, width of mediastinum, whether or not the patient underwent an operation, number of days spent hospitalized, and in-hospital mortality rates. We found that in the elderly group there were more instances of hyperglycemia (p=0.0001), more neurologic defects (p=0.001), less chest pain (p=0.001), and less abdominal pain (p=0.003). SBP was also lower in the elderly group (139±48mmHg, p=0.0001), while there was no difference in mediastinal width between these two groups. In both groups, most AAD cases were DeBakey type III, but type I AAD was more commonly seen in the elderly (p=0.0011). We found that there were both lower SBP and higher rate of diabetes in the elderly group. The elderly group also had longer hospital stays (14.6±16.3 days, p=0.0001) and almost twice the mortality rate (31.1% vs. 15.8%, p=0.0001).

Elderly, hypotension and presentation of neurologic symptoms are risk factors of mortality in aortic dissection

mortality in aortic dissection Yu-Jang Su ⁎, Yen-Chun Lai , Yu-Hang Yeh , Che-Hung Liu a a Department of Emergency Medicine, Mackay Memorial Hospital, No. 92, Sec 2, Chung-Shan North Rd., Taipei 10449, Taiwan b Department of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan c Mackay Medicine, Nursing and Management College, No. 92, Shengjing Rd., Beitou District, Taipei 112, Taiwan d Department of Anesthesiology, Taiwan Adventist Hospital, Taipei, Taiwan

Treat the patient by the recognized toxidrome when the ingested herbal juice is non-toxic

This is the case of 63-year-old mother and her 35-year-old daughter who drank herbal juice (Rhizoma Dioscoreae Nipponicae and Ficus formosana Maxim) and then developed diarrhea, cold sweating, and myoclonus. On physical examination, the mother had a normal consciousness level, a normal respiratory rate, and bilateral miosis. After the administration of 2xa0g of pralidoxime (PAM) and 0.5xa0mg of atropine, the mother felt better. The daughter only had mild symptoms of sweating and vomiting before arrival at the emergency department (ED).The poison center of our hospital was consulted, and they assured us that the herbs ingested were all non-toxic. In conclusion, the majority of emergency physicians are not familiar with herbal medicines and plants. In this instance, however, it was more important to apply appropriate early management according to the toxidrome rather than to recognize what kind of herb had been ingested.

Hypoglycemia in Emergency Department

Abstract Objective To study the epidemiology, etiologies and prognostic factors of hypoglycemia. Methods A retrospective chart review of hypoglycemic cases from December, 2009 to February, 2012 was conducted to gather the following patient data: age, gender, vital signs at triage, white blood cell count, serum glucose, C-reactive protein, glutamic oxaloacetic transaminase, creatinine, sodium, potassium, past history of liver cirrhosis, uremia, concomitant infection, concomitant cancer/malignancy, length of stay, lack of recent meal, status of acute renal failure and concomitant stroke. A total of 186 cases were enrolled in our study. We analyzed the data using commercial statistics software (SPSS for Windows, version 11.0, SPSS Inc., Chicago, IL). We used the Students t-test and χ2 test for the statistical analyses, and significance was set at a P value less than 0.05. Results Hypoglycemia is related to several co-morbidities. In total, 10.2% of the patients had liver cirrhosis and 7.0% had uremia. More than half (55.4%) were bacterial infection during hospitalization. Acute renal failure accounted for 26.3% of the hypoglycemic episodes. In addition to the etiology of infection, the lack of a recent meal accounted for 44.6% hypoglycemic episodes. A total of 2.2% of the cases resulted from an acute cerebrovascular accident. Approximately 8.6% were concomitant with malignancy. Conclusions When hypoglycemic patients present in the emergency department, physicians should pay attention to the presence of infection, malignancy, liver diseases (liver cirrhosis and biliary tract infection), and acute renal failure.

Sonographic Detection of Pseudoaneurysm in Vascular Injury in Emergency Department

A 31-year-old man suffered from a stab wound to the lower extremity. The patient had a hard sign of a vascular injury (a diminished distal pulse) and therefore probably should have undergone operative repair, but refused. One week later, he returned to our emergency department with a painful right thigh swelling. Bedside sonography was used to detect a pseudoaneurysm. Emergency sonography is a fast, non-invasive, and rapid decision-making approach in emergency practice.

A Report of Acute Atrial Fibrillation Induced by Misapplication of Epinephrine

Urticaria is a systemic allergic reaction leading to wheal formation with skin itching. Occasionally we come across some intractable cases, in which we may administrate epinephrine infusion besides steroid and anti-histamine. A 19 year-old man suffered from intractable urticaria for 2 days, although anti-histamine and steroids were used. Titration of adrenaline was considered in the treatment of intractable urticaria. He was administrated 1 mg epinephrine intravenous bolus due to mis-dilution by the nurse. Transient atrial fibrillation with cardiac ischemia occurred. After 12.5 mg labetalol i.v., and 11-hour observation in the emergency room, he gradually recovered to normal sinus rhythm without ST-T change. In the past, ventricular tachycardia, hypertension, chest pain, pulmonary edema, the need to intubate, renal failure requiring renal transplant, coronary artery spasm, myocardial ischemia/infarction and hypokalemia have been reported after mis-diluted or excessive doses of epinephrine in treating anaphylaxis. To our knowledge, our case is the first worldwide to describe transient atrial fibrillation after epinephrine overdose, and the patient was successfully resuscitated by 12.5 mg labetalol. It is important to know how to rescue accidental epinephrine intravenous injection patients.

Gender-Differences in aortic dissection

Abstract Objectives Aortic dissection is a truly emergency in daily practice, and for gender factor, we want to compare the epidemiology, biomarkers, symptoms and outcome. Methods A retrospective review six-year AD cases in a northern Taiwan medical center from January, 1, 2005 to December, 31, 2010. by gathering data of 134 AD patients including gender, age, episodes of time, season, vital signs, symptoms (chest pain, chest tightness (CP/CT), abdominal pain, neurological symptoms), Stanford classifications, and outcome. Comparisons are made by gender of AD groups. 85 cases with complete data are strictly enrolled into our study. We used student t test and one way ANOVA for statistical analyses, and significance was set at a P value less than 0.05 (2-tailed). Results There are 64 male and 21 female enrolled into our study with the mean ± standard deviation (SD) of age is (64.1±14.0) years old. In AD patients with female gender are older than male AD patients (71.5 vs. 61.6 years old, P value Conclusion Female AD patients are ten-year older in age than male, and have more common neurologic symptoms in presentations, and female AD patient have 2-fold mortality rate than male AD patients.

Uncommon Clavicle Fracture that Could be Easily Overlooked

*Department of EmergencyMedicine,MackayMemorial Hospital, Taipei, Taiwan, †Department of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan, ‡Department of Emergency Medicine, Tao-Yuan General Hospital, Tao-Yuan, Taiwan, and §Department of Anesthesiology, Taiwan Adventist Hospital, Taipei, Taiwan Reprint Address: Yu-Jang Su, MD, Department of Emergency Medicine, Mackay Memorial Hospital, No. 92, Sec. 2, North Chung-Shan Road, Taipei 10449, Taiwan

Abdominal Lump in an Old Woman

An 89-year-old woman presented to our emergency department with persistent epigastralgia and vomiting for 2 days. She was afebrile and mildly tachycardiac (pulse rate 101 beats/min). Physical examination revealed a masslike lesion beneath the umbilicus (Figure 1). Blood tests showed leukocytosis (WBC count 21,600/ L; neutrophil 96%). Kidney ureter bladder abdominal radiograph revealed a small bowel gas collection with a large radiopacity in the lower abdomen. Figure 1. Physical examinations showed a masslike lesion palpated beneath the umbilicus. Figure 2. A round radiopacity was observed over the lower abdomen on radiograph (white arrows). The second image is the computed tomography of the abdomen. Used with permission of Yu-Jang Su, MD, Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan.