Novel Prediction Score for Arterial-Esophageal Fistula in Patients with Esophageal Cancer Bleeding: A Multicenter Study

PURPOSE

To develop and internally validate a novel prediction score to predict the occurrence of arterial-esophageal fistula (AEF) in esophageal cancer bleeding.

METHODS

This retrospective cohort study enrolled patients with esophageal cancer bleeding in the emergency department. The primary outcome was the diagnosis of AEF. The patients were randomly divided into a derivation group and a validation group. In the derivation stage, a predictive model was developed using logistic regression analysis. Subsequently, internal validation of the model was conducted in the validation cohort during the validation stage to assess its discrimination ability.

RESULTS

A total of 257 patients were enrolled in this study. All participants were randomized to a derivation cohort (n = 155) and a validation cohort (n = 102). AEF occurred in 22 patients (14.2%) in the derivation group and 14 patients (13.7%) in the validation group. A predictive model (HEARTS-Score) comprising five variables (hematemesis, active bleeding, serum creatinine level >1.2 mg/dL, prothrombin time >13 s, and previous stent implantation) was established. The HEARTS-Score demonstrated a high discriminative ability in both the derivation and validation cohorts, with c-statistics of 0.90 (95% CI 0.82-0.98) and 0.82 (95% CI 0.72-0.92), respectively.

CONCLUSIONS

By employing this novel prediction score, clinicians can make more objective risk assessments, optimizing diagnostic strategies and tailoring treatment approaches.

Influences of Cognitive Function and Depressive Symptoms on Pain Trajectories During the First Year Following Hip Fracture Surgery: A Prospective Cohort Study

OBJECTIVES

The purposes of this study were to explore trajectories for patterns of postoperative pain intensity during the first year following hip fracture surgery and the relationships between pain trajectory groups, cognitive impairment, and depressive symptoms.

DESIGN

A prospective cohort correlational study.

SETTING AND PARTICIPANTS

A total of 325 patients aged 60 years or older who had received hip fracture surgery at a 3000-bed medical center in northern Taiwan from September 2012 to March 2020.

METHODS

Data were collected before hospital discharge and at 1, 3, 6, and 12 months postdischarge. Pain intensity was measured using a numeric rating scale; cognitive function was measured with the Taiwan version of the Mini-Mental State Examination; and depressive symptoms were measured by the Geriatric Depression Scale-Short Form. Patients with similar postoperative pain trajectories were categorized into groups and compared with group-based trajectory modeling. Cognitive impairment and depressive symptoms associated with each group were identified by logistic regression.

RESULTS

Three different pain trajectory groups were identified: drastic decline-minimum pain (47.7%), gentle decline-mild pain (45.5%), and slight decline-moderate pain (6.8%). Patients with cognitive impairment [odds ratio (OR) 11.01, 95% CI 2.99-10.51] and at risk for depression (OR 49.09, 95% CI 10.46-230.30) were more likely to be in the moderate pain group than the minimum pain group. Patients with cognitive impairment (OR 2.07, 95% CI 1.25-3.42) were more likely to be in the mild pain group than the minimum pain group. Patients at risk for depression (OR 9.68, 95% CI 3.16-29.63) were more likely to be in the moderate pain group than the mild pain group.

CONCLUSIONS AND IMPLICATIONS

Identifying postoperative pain trajectories can provide insight into the most appropriate pain management for older persons following hip fracture surgery. Attention should focus on assessments for cognitive impairment and risk of depression to prevent persistent postoperative pain. Future studies of older patients with clinically diagnosed cognitive impairment and depression are suggested.

Low-to-Moderate Arsenic Exposure and Urothelial Tract Cancers with a Long Latent Period of Follow-Up in an Arseniasis Area

BACKGROUND

Arsenic exposure can cause adverse health effects. The effects of long-term low-to-moderate exposure and methylations remain unclear.

OBJECTIVE

This study aims to examine the association between low-to-moderate arsenic exposure and urothelial tract cancers while considering the effects of methylation capacity.

METHODS

In this study, 5,811 participants were recruited from an arseniasis area in Taiwan for inorganic arsenic metabolite analysis. This follow-up study was conducted between August 1995 and December 2017. We identified 85 urothelial tract cancers in these participants, including 49 bladder and 36 upper urothelial tract cancer cases. A Cox proportional hazards model was employed.

RESULTS

The analyses revealed a significant association between concentrations of inorganic arsenic in water > 100 ug/L and bladder cancer occurrence, with a hazard ratio (HR) of 4.88 (95% CI 1.35-17.61). A monotonic trend was observed between concentrations of inorganic arsenic in water (from 0 to > 100 ug/L) and the incidence of urothelial tract cancer, including bladder cancer (p < 0.05) and upper urothelial tract cancers (p < 0.05). Participants with a lower primary methylation index or higher secondary methylation index had a prominent effect.

CONCLUSIONS

Rigorous regulations and active interventions should be considered for populations with susceptible characteristics.

Case report: Duodenal obstruction caused by gastroduodenal artery pseudoaneurysm with hematoma: an unusual case and literature review

Visceral artery pseudoaneurysm is a rare disease that most commonly occurs in male patients in their 50s, with gastroduodenal artery (GDA) pseudoaneurysm accounting for only 1.5% of these. The treatment options generally include open surgery and endovascular treatment. In 40 cases of GDA pseudoaneurysm from 2001 to 2022, endovascular therapy was the mainstay of treatment in 30 cases, and most of them (77%) were treated by coil embolization. Our case report describes a 76-year-old female patient with a GDA pseudoaneurysm, which was treated by endovascular embolization using liquid embolic agent N-butyl-2-cyanoacrylate (NBCA) alone. This is the first time this treatment strategy has been used for GDA pseudoaneurysm. We demonstrate a successful outcome with this unique treatment. The successful experience of our case may provide a new treatment strategy for this rare disease.

The Distribution Trend and Antimicrobial Susceptibility of Uropathogens in Taiwan: Retrospective Analysis of a 10-Year Study

Background: The prevalence and antimicrobial susceptibility of uropathogens can vary with time and geographical location. Empirical antibiotic treatment is frequently started before the urine culture reports are received; thus, the correct selection of antibiotics is imperative, as inappropriate use could increase resistance rates. This study evaluates the distribution trends and antimicrobial susceptibility of common uropathogens in Taiwan to help predict causative pathogens, prevent overly broad antibiotic use, and guide the optimal prescription of empirical antibiotic therapy to improve prognosis. Methods: This retrospective study extracted 5,672,246 urine culture sample data, including outpatient, emergency, and inpatient departments, during 2007-2017 from the Chang Gung Research Database. We examined the trend and susceptibility of uropathogens. Results: The three leading microorganisms were Escherichia coli (E. coli), Klebsiella pneumoniae (K. pneumoniae), and Pseudomonas aeruginosa (P. aeruginosa). E. coli. was more common among females (42.7%) than males (24.7%), while P. aeruginosa was more common among males (10.2%) than females (4.42%). E. coli and K. pneumoniae were highly susceptible to carbapenems, followed by aminoglycosides. Nevertheless, an increased antimicrobial resistance trend was observed in cephalosporins and quinolones. Conclusions: This study establishes E. coli and K. pneumoniae as the predominant uropathogens. Age and gender of patients result in distribution variations of uropathogens, but geographical location does not. In addition, P. aeruginosa occurs more in the sample of elderly and that too among males. Overall, this study could help clinicians choose appropriate antibiotics to treat urinary tract infections per the prevalent uropathogens and local antimicrobial susceptibility patterns.

Case report: Aortoesophageal fistula-an extremely rare but life-threatening cardiovascular cause of hematemesis

Aortoesophageal fistula (AEF) is an extremely rare cardiovascular etiology of hematemesis and upper gastrointestinal bleeding. As such, its recognition and diagnosis are challenging and may be delayed when such patients present to the emergency department (ED). Without timely surgical intervention, AEF is almost always fatal. Awareness of AEF as a possible diagnosis and consequently early identification of these patients presenting to the ED are therefore crucial in optimizing clinical outcomes. We report a 45-year-old male presenting to the ED with the classical triad of an AEF (Chiari's triad)-midthoracic pain or dysphagia, a sentinel episode of minor hematemesis, then massive hematemesis with risk of exsanguination. The case report highlights the importance of considering the differential diagnosis of AEF when evaluating patients presenting to the ED with hematemesis, especially if they have predisposing risk factors such as prior aortic or esophageal surgeries, aortic aneurysms, or thoracic malignancies. Patients suspected of having AEF should be prioritized for early computed tomography angiography to expedite diagnosis and treatment.

Combined Effects of Cognitive Impairment and Nutritional Trajectories on Functional Recovery for Older Patients after Hip-Fracture Surgery

OBJECTIVES

Malnutrition and cognitive impairment are associated with poor functional recovery in older adults following hip-fracture surgery. This study examined the combined effects of cognitive impairment and nutritional trajectories on postoperative functional recovery for older adults following hip-fracture surgery.

DESIGN

Prospective longitudinal correlational study.

SETTING AND PARTICIPANTS

This study recruited 350 older adults (≥60 years of age) who received hip-fracture surgery at a 3000-bed medical center in northern Taiwan from September 2012 to March 2020.

METHODS

Participant data were collected over a 2-year period after surgery for nutritional and cognitive status and activities of daily living (ADLs). Participants were grouped by type of nutritional trajectory using group-based trajectory modeling. Generalized estimating equations analyzed associations between trajectory groups/cognitive status at discharge and performance of ADLs.

RESULTS

Nutritional trajectories best fit a 3-group trajectory model: malnourished (19%), at-risk of malnutrition (40%), and well-nourished (41%). Nutritional status for the malnourished group declined from 12 months to 24 months following surgery; nutritional status remained stable for at-risk of malnutrition and well-nourished groups. Interactions for cognitive impairment-by-nutritional status were significant: the malnourished + intact cognition subgroup had significantly better ADLs than the malnourished + cognitive impairment subgroup (b = 27.1, 95% confidence interval = 14.0-40.2; P < .001). For at-risk of malnutrition and well-nourished groups, there were no significant differences between cognitive impairment and intact cognition in ADLs. These findings suggest that nutritional status may buffer the negative effect of cognitive impairment on ADLs.

CONCLUSIONS AND IMPLICATIONS

Better nutritional status over time for older adults following hip fracture can protect against adverse influences of cognitive impairment on ADLs during postoperative recovery. Participants with malnutrition and cognitive impairment had the poorest ADLs. These findings suggest interventions tailored to improving nutritional status may improve recovery for older adults following hip-fracture surgery.

When a Rapid Accurate Diagnosis Changes Therapeutic Approach: Recognizing Acute Abdominal Pain with Ascites as a Possible Presentation of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a chronic, multi-organ autoimmune disease which rarely presents with peritoneal involvement. As such, its diagnosis in the emergency department (ED) based on a clinical presentation of gastrointestinal symptoms is extremely challenging. Yet, reaching such a diagnosis in the ED is crucial for avoiding unnecessary surgical intervention and initiating early glucocorticoid therapy to maximise patient outcomes. Here, we report a case of newly diagnosed SLE in a 28-year-old lady who presented atypically and unusually with abdominal pain and ascites. She required extensive but methodical investigations, and was eventually diagnosed with lupus mesenteric vasculitis with underlying newly diagnosed SLE in the ED. The patient was promptly treated with methylprednisolone resulting in marked clinical improvement. Emergency physicians should be mindful of abdominal pain with ascites as an extremely rare but important clinical presentation of SLE. Early diagnosis and commencement of glucocorticoid therapy in these patients are crucial in halting disease progression and averting the need for surgical intervention.

Dual Antiplatelet Therapy in the Management of Acute Minor Ischemic Stroke and High-Risk Transient Ischemic Attack: An Expert Consensus Statement From Taiwan Stroke Society and Taiwan Society of Emergency Medicine

The aim of this review is to achieve a consensus between Taiwan Stroke Society (TSS) and Taiwan Society of Emergency Medicine (TSEM) to manage acute non-cardioembolic minor ischemic stroke (MIS) and high-risk transient ischemic attack (TIA). The methodology is to review the recent findings from clinical trials of dual antiplatelet therapy (DAPT) from 2010 to 2021 and updates in clinical practice guidelines from 2018 to 2022 for non-cardioembolic MIS/TIA management at the acute stage. Four leading clinical studies, CHANCE, POINT, THALES, and CHANCE-2 along with other relevant studies introducing DAPT, are discussed in this review. The risk-benefit profile between stroke recurrence reduction and major bleeding increase is also elucidated. TSS and TSEM concluded that for patients presenting with non-cardioembolic MIS or high-risk TIA who did not receive intravenous alteplase, initiation of DAPT within 24 hours after stroke onset and continued up to 21 days, followed by antiplatelet monotherapy, is effective in reducing recurrent ischemic stroke for a period of up to 90 days.

Point-of-care application of diaphragmatic ultrasonography in the emergency department for the prediction of development of respiratory failure in community-acquired pneumonia: A pilot study

Background

Early recognition of patients with community-acquired pneumonia (CAP) at risk of poor outcomes is crucial. However, there is no effective assessment tool for predicting the development of respiratory failure in patients with CAP. Diaphragmatic ultrasonography (DUS) is a novel technique developed for evaluating diaphragmatic function via measurements of the diaphragm thickening fraction (DTF) and diaphragm excursion (DE). This study evaluated the accuracy of DUS in predicting the development of respiratory failure in patients with CAP, as well as the feasibility of its use in the emergency department (ED) setting.

Materials and methods

This was a single-center prospective cohort study. We invited all patients with ED aged ≥ 20 years who were diagnosed with CAP of pneumonia severity index (PSI) SIe diagnosed with CAP of pneumonia severe with respiratory failure or septic shock were excluded. Two emergency physicians performed DUS to obtain DTF and DE measurements. Data were collected to calculate PSI, CURB-65 score, and Infectious Diseases Society of America/American Thoracic Society severity criteria. Study endpoints were taken at the development of respiratory failure or 30 days post-ED presentation. Continuous variables were analyzed using T-tests, while categorical variables were analyzed using chi-square tests. Further logistic regression and receiver operating characteristic curve analyses were performed to examine the ability to predict the development of respiratory failure. Intra- and inter-rater reliability was examined with intraclass correlation coefficients (ICCs).

Results

In this study, 13 of 50 patients with CAP enrolled developed respiratory failure. DTF was found to be an independent predictor (OR: 0.939, p = 0.0416). At the optimal cut-off point of 23.95%, DTF had 69.23% of sensitivity, 83.78% of specificity, 88.57% of negative predictive value, and 80% of accuracy. Intra- and inter-rater analysis demonstrated good consistency (intra-rater ICC 0.817, 0.789; inter-rater ICC 0.774, 0.781).

Conclusion

DUS assessment of DTF may reliably predict the development of respiratory failure in patients with CAP presenting to the ED. Patients with DTF > 23.95% may be considered for outpatient management.

At the heart of the problem: congestive cardiac failure as a cause of ascites: A narrative review

Heart failure leading to cardiac ascites is an extremely rare and underrecognized entity in clinical practice. Recognizing cardiac ascites can be difficult, especially since patients presenting with ascites may have more than 1 etiology. Various biomarkers are available to aid in the diagnosis of cardiac ascites, though with differing sensitivities and specificities. Such biomarkers include serum albumin, ascitic albumin and protein, as well as serum N-terminal pro-brain natriuretic peptide (NT-proBNP). While serum NT-proBNP is a powerful biomarker in distinguishing the etiology of ascites and monitoring treatment progression, its cost can be prohibitive in low-resource settings. Clinicians practicing under these circumstances may opt to rely on other parameters to manage their patients. We go on further to report a series of 3 patients with cardiac ascites to illustrate how these biomarkers may be employed in the management of this patient population. Clinicians should always keep in mind the differential diagnosis of cardiac failure as a cause of ascites. The resolution of cardiac ascites may serve as a surrogate clinical marker for response to antifailure therapy in lieu of NT-proBNP at resource-scarce centers.

Intentional avermectin pesticide ingestion: a retrospective multicenter study

CONTEXT

Avermectin pesticides are widely used in agriculture, and are thought to have low toxicity in humans. However, information on their toxicity after accidental or deliberate ingestion is limited.

OBJECTIVE

The aim of this study was to evaluate the clinical manifestations of avermectin pesticide ingestion and identify factors associated with severe outcomes (death, intubation, or sustained hypotension requiring inotrope therapy).

MATERIALS AND METHODS

This multicenter retrospective study included patients who visited the emergency departments of six teaching hospitals due to acute avermectin pesticide ingestion between January 2012 and May 2020. Patients who reported ingestion of any other pesticides, drugs, or substances were excluded.

RESULTS

In total, 64 patients (median age, 72 years) were included: 60 had ingested emamectin pesticides, and 4 had ingested abamectin. Almost all (98%) were cases of self-harm. The most common presentation was drowsiness (47%), with a median Glasgow Coma Scale (GCS) score of 14, followed by shortness of breath (SOB)/dyspnea (33%) and nausea/vomiting (22%). Concurrent methanol exposure (via the solvent) was confirmed or suspected in five patients. Seventeen patients (27%) were intubated. Three patients who developed respiratory failure were not intubated because of a "do-not-resuscitate" (DNR) order. Four patients developed sustained hypotension requiring inotrope therapy. Fifty patients (78%) were admitted, of whom 27 (42%) required intensive care unit (ICU) admission. Four patients died, three of whom had a DNR order. Based on our definition, 20 patients (31%) had severe outcomes. A multivariate logistic regression model showed that a GCS score < 13 (OR 68.1, 95% CI 3.8-999) and the presence of SOB/dyspnea (OR 50.2, 95% CI 3.0-849.9) were associated with severe outcomes.

CONCLUSIONS

Most patients who intentionally ingested avermectin pesticides required inpatient treatment. Forty-two percent needed ICU care and 31% had severe outcomes. A GCS score < 13 and SOB/dyspnea were independently associated with severe outcomes.

Management and Prognosis of Snake Envenomation Among Pediatric Patients: A National Database Study

BACKGROUND

Snakebites constitute a common medical emergency in tropical and subtropical regions. Pediatric snake envenomation is a special category that has not been well studied. This study investigated the management and prognostic factors of snake envenomation in children using a Taiwanese national database.

METHODS

This observational study used the National Health Insurance database of all pediatric snake envenomation patients treated from 2005 to 2009. Patients' demographic data, antivenom types and doses, medical and surgical interventions, and prognostic variables were collected. Comparisons were made according to the envenomation types, age groups, and whether the patients were hospitalized using univariate and multivariate methods.

RESULTS

A total of 106 patients' data were collected. Of the patients, 73 (68.9%) were male, 62 (58.5%) were under the age of 12, 69 (65.1%) received intravenous (IV) antibiotic treatment, 38 (35.9%) were hospitalized, 5 (4.72%) required surgical intervention, and none died. Compared with non-hospitalized patients, the patients who required hospitalization were more likely to have suffered hemorrhagic envenomation ( p = 0.035), receive IV antibiotic treatment ( p = 0.0078), and require surgical intervention ( p = 0.005). In the multivariate analysis, hemorrhagic envenomation was an independent predictor for hospitalization (odds ratio: 3.47, 95% confidence interval: 1.18-10.21) after adjusting for other covariates. No significant differences were observed between age groups in total antivenom usage ( p = 0.2880), IV antibiotic usage ( p = 0.3190), hospitalization ( p = 0.3988), and surgical intervention ( p = 0.1874).

CONCLUSIONS

In this Taiwanese population-based national database study, antivenom treatment of pediatric snakebite patients resulted in zero mortality and a low surgical intervention rate. Patients with hemorrhagic envenomation were associated with a higher probability of hospitalization.

Methanol Intoxication After Suicidal Ingestion of Liquid Rodenticides: A Report of Two Cases

Methanol is highly toxic to humans. Although methanol poisoning is not uncommon in developing countries, poisoning caused by ingestion of commercial products containing undeclared methanol has rarely been reported. Herein, we describe two patients who experienced methanol poisoning after ingestion of liquid rodenticides. A 39-year-old woman attempted suicide by ingesting liquid rodenticide which contained bromadiolone. She developed high anion gap metabolic acidosis and coagulopathy. Methanol poisoning was confirmed 20 hours later. She received oral ethanol therapy and hemodialysis. Vitamin K1 was also administered. She did not develop any hemorrhage or visual impairment and was discharged after 11 days. The rodenticide sample was tested and found to have a methanol concentration of 324 g/L. In another case, a 62-year-old man ingested the same brand of rodenticide. Laboratory data showed mild metabolic acidosis with an increased osmol gap, suggestive of methanol poisoning. He received hemodialysis and eventually recovered without sequelae. Liquid rodenticide may contain methanol as a solvent. Ingestion of a methanol-containing commercial product without a clear label can result in a considerable delay in diagnosis and management. Methanol poisoning should be considered for patients who present with unexplained metabolic acidosis following exposure to liquid rodenticides or other liquid commercial products.

Comparison of the diagnostic accuracy of monocyte distribution width and procalcitonin in sepsis cases in the emergency department: a prospective cohort study

Background

Early diagnosis and treatment of patients with sepsis reduce mortality significantly. In terms of exploring new diagnostic tools of sepsis, monocyte distribution width (MDW), as part of the white blood cell (WBC) differential count, was first reported in 2017. MDW greater than 20 and abnormal WBC count together provided a satisfactory accuracy and was proposed as a novel diagnostic tool of sepsis. This study aimed to compare MDW and procalcitonin (PCT)’s diagnostic accuracy on sepsis in the emergency department.

Methods

This was a single-center prospective cohort study. Laboratory examinations including complete blood cell and differentiation count (CBC/DC), MDW, PCT were obtained while arriving at the ED. We divided patients into non-infection, infection without systemic inflammatory response syndrome (SIRS), infection with SIRS, and sepsis-3 groups. This study’s primary outcome is the sensitivity and specificity of MDW, PCT, and MDW + WBC in differentiating septic and non-septic patients. In addition, the cut-off value for MDW was established to maximize sensitivity at an optimal level of specificity.

Results

From May 2019 to September 2020, 402 patients were enrolled for data analysis. Patient number in each group was: non-infection 64 (15.9%), infection without SIRS 82 (20.4%), infection with SIRS 202 (50.2%), sepsis-3 15 (7.6%). The AUC of MDW, PCT, and MDW + WBC to predict infection with SIRS was 0.753, 0.704, and 0.784, respectively (p < 0.01). The sensitivity, specificity, PPV, and NPV of MDW using 20 as the cutoff were 86.4%, 54.2%, 76.4%, and 70%, compared to 32.9%, 88%, 82.5%, and 43.4% using 0.5 ng/mL as the PCT cutoff value. On combing MDW and WBC count, the sensitivity and NPV further increased to 93.4% and 80.3%, respectively. In terms of predicting sepsis-3, the AUC of MDW, PCT, and MDW + WBC was 0.72, 0.73, and 0.70, respectively. MDW, using 20 as cutoff, exhibited sensitivity, specificity, PPV, and NPV of 90.6%, 37.1%, 18.7%, and 96.1%, respectively, compared to 49.1%, 78.6%, 26.8%, and 90.6% when 0.5 ng/mL PCT was used as cutoff.

Conclusions

In conclusion, MDW is a more sensitive biomarker than PCT in predicting infection-related SIRS and sepsis-3 in the ED. MDW < 20 shows a higher NPV to exclude sepsis-3. Combining MDW and WBC count further improves the accuracy in predicting infection with SIRS but not sepsis-3.

Trial registration The study was retrospectively registered to the ClinicalTrial.gov (NCT04322942) on March 26th, 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06999-4.

Two-stage prediction model for in-hospital mortality of patients with influenza infection

BACKGROUND

Infleunza is a challenging issue in public health. The mortality and morbidity associated with epidemic and pandemic influenza puts a heavy burden on health care system. Most patients with influenza can be treated on an outpatient basis but some required critical care. It is crucial for frontline physicians to stratify influenza patients by level of risk. Therefore, this study aimed to create a prediction model for critical care and in-hospital mortality.

METHODS

This retrospective cohort study extracted data from the Chang Gung Research Database. This study included the patients who were diagnosed with influenza between 2010 and 2016. The primary outcome of this study was critical illness. The secondary analysis was to predict in-hospital mortality. A two-stage-modeling method was developed to predict hospital mortality. We constructed a multiple logistic regression model to predict the outcome of critical illness in the first stage, then S1 score were calculated. In the second stage, we used the S1 score and other data to construct a backward multiple logistic regression model. The area under the receiver operating curve was used to assess the predictive value of the model.

RESULTS

In the present study, 1680 patients met the inclusion criteria. The overall ICU admission and in-hospital mortality was 10.36% (174 patients) and 4.29% (72 patients), respectively. In stage I analysis, hypothermia (OR = 1.92), tachypnea (OR = 4.94), lower systolic blood pressure (OR = 2.35), diabetes mellitus (OR = 1.87), leukocytosis (OR = 2.22), leukopenia (OR = 2.70), and a high percentage of segmented neutrophils (OR = 2.10) were associated with ICU admission. Bandemia had the highest odds ratio in the Stage I model (OR = 5.43). In stage II analysis, C-reactive protein (OR = 1.01), blood urea nitrogen (OR = 1.02) and stage I model's S1 score were assocaited with in-hospital mortality. The area under the curve for the stage I and II model was 0.889 and 0.766, respectively.

CONCLUSIONS

The two-stage model is a efficient risk-stratification tool for predicting critical illness and mortailty. The model may be an optional tool other than qSOFA and SIRS criteria.

2020 Guideline for Prehospital Management, Emergency Evaluation and Treatment of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the Taiwan Society of Emergency Medicine and Taiwan Stroke Society

To improve the clinical outcomes of patients with acute ischemic stroke, the public, pre-hospital care system, and hospitals should cooperate to achieve quick assessment and management for such patients and to start treatment as soon as possible. To reach the goal, the Consensus Group, including emergency physicians and neurologists in the Taiwan Society of Emergency Medicine and Taiwan Stroke Society, performed an updated review and discussion for the local guidelines. The guidelines consist of 12 parts, including public education program, evaluation and management in the emergency medical system, emergency medical system, assessment of stroke care capability of the hospital by independent parties, stroke team of the hospital, telemedicine, organization, and multifaceted integration, improvement of quality of care process of stroke system, initial clinical and imaging evaluations after arriving at the hospital, imaging evaluation for indications of intravenous thrombolysis, imaging evaluation for indications of endovascular thrombectomy, and other diagnostics. For detailed contents in Chinese, please refer to the Taiwan Stroke Society Guideline and Taiwan Emergency Medicine Bulletin.

Impact of the Coronavirus Disease 2019 Pandemic on an Emergency Department Service: Experience at the Largest Tertiary Center in Taiwan

Purpose

Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) is an emerging contagious pathogen that has caused community and nosocomial infections in many countries. This study aimed to evaluate the impact of Coronavirus disease 2019 (COVID-19) on emergency services of the largest medical center in Taiwan by comparing emergency department (ED) usage, turnover, and admission rates before the COVID-19 outbreak with those during the outbreak.

Materials and Methods

A retrospective cohort study was conducted in the ED of the largest tertiary medical center in Taiwan. Trends of adult, non-trauma patients who visited the ED during February-April 2019 were compared with those during February-April 2020. The number of visits, their dispositions, crowding parameters, and turnover rates were analyzed. The primary outcome was the change in ED attendance between the two periods. The secondary outcomes were changes in hospital admission rates, crowding parameters, and turnover rates.

Results

During the outbreak, there were decreased non-trauma ED visits by 33.45% (p < 0.001) and proportion of Taiwan Triage and Acuity Scale (TTAS) 3 patients (p=0.02), with increased admission rates by 4.7% (p < 0.001). Crowding parameters and turnover rate showed significant improvements.

Conclusion

Comparison of periods before and during the COVID-19 outbreak showed an obvious decline in adult, non-trauma ED visits. The reduction in TTAS 3 patient visits and the increased hospital admission rates provide references for future public-health policy-making to optimise emergency medical resource allocations globally.

Do initially non-dehydrated patients with acute ischemic stroke need fluid supplement?

Background: We previously found that dehydration is an independent predictor of early deterioration after acute ischemic stroke and rehydration helps to improve outcomes. There is limited evidence of how to treat patients who are initially non-dehydrated. In this study, we tested the hypothesis that rehydration therapy, based on the daily urine specific gravity, will improve the outcome of ischemic stroke patients who are initially non-dehydrated. Methods: We conducted a single-arm prospective study of patients with acute ischemic stroke with historical controls. For the first 5 days of study group, a daily urine specific gravity of > 1.020 g/ml was taken as indication for rehydration and patients were advised to drink water via oral or tubal feeding with a dose of 5 ml/kg body weight right away and after dinner. Control group patients were rehydrated without reference to urine specific gravity. An increase in National Institutes of Health Stroke Scale score of ≥ 4 within three days was defined as having stroke-in-evolution. Scores of ≤ 1 on the modified Rankin scale at 3 months were considered to indicate a favorable outcome. Results: A total of 125 patients were analyzed, 46 in the study group and 79 in the control group. The groups did not significantly differ in the stroke-in-evolution rate (4.3% vs. 8.2%, P = 0.474). The rate of favorable outcome at 3 months was significantly higher in the study group than in the control group (56.5% vs. 27.8%, P = 0.001). Conclusions: Urine specific gravity-based hydration might be a useful method to improve functional outcomes of patients with acute ischemic stroke who were non-dehydrated at admission.

A new perspective of the risk of caustic substance ingestion: the outcomes of 468 patients in one North Taiwan medical center within 20 years

INTRODUCTION

Caustic substance ingestion is frequently life-threatening, and its pathological mechanisms of tissue damage are well documented. However, few studies have assessed the combined effects of pH and the ingested dose on patient outcomes. Additionally, the miscellaneous chemical properties are not immediately available for providing predictive insights to physicians. This study aimed to provide a new perspective of the risk assessment of caustic substance ingestion based on the pH and dose.

METHODS

The retrospective study analyzed adults treated for caustic substance ingestion at Chang Gung Memorial Hospital between January 1999 and December 2018. Uniformly strict inclusion/exclusion criteria and a double-checked process during chart review were adopted. All patients underwent urgent esophagogastroduodenoscopy (EGD) within 24 h. Caustic mucosal damage was graded using Zargar's modified endoscopic classification. The pH and ingested dose of caustic substances were clearly recorded. Statistical analyses were conducted using IBM SPSS, version 22.

RESULTS

Based on the 468 enrolled cases, the pH and dose were valuable predictors of the extent of gastrointestinal tract injury, commonly encountered complications, and long-term overall survival outcomes. Risks of mortality and perforation were dose-dependent for acids and pH-dependent for alkalis. The severe EGD findings (grade ≥ 2b) in this study were pH-dependent for both substances and additionally dose-dependent for acids.

CONCLUSION

Combining pH and dose, we proposed a new perspective for the risk assessment of caustic substance ingestion. Such findings may provide predictive insights for resolving clinical uncertainty before the availability of examination results. "Large doses of acids" and "high pH of alkalis" deserve special attention. This new perspective with a retrospective nature requires further validation.

The Association Between Caustic Ingestion and Psychiatric Comorbidity Based on 396 Adults Within 20 Years

Purpose

High prevalence of psychiatric comorbidities (PCs) has been widely documented in caustic substance ingestion cases. However, their effect on the clinical features and prognostic outcomes remains unclear due to the paucity of discussion. We report on detailed clinical courses with long-term multifaceted outcomes and review the association between caustic ingestion and each specific PC.

Patients and Methods

The retrospective chart review included 396 adults (median follow-up, 16.6 months) with and 377 without (control group) PCs treated between 1999 and 2018 at Chang Gung Memorial Hospital. All PCs were diagnosed/confirmed by psychiatrists through face-to-face interviews.

Results

The PCs predicted serious esophagogastroduodenoscopy grading, higher rates of admission/surgery/intensive care unit stay, increments of systemic/gastrointestinal complications, and poorer 5-year overall survival rates. The poor survival among patients with PCs was highly consistent with their baseline characteristics. Significantly advanced age, more non-PCs, alcoholism, illicit drug abuse, and baseline unhealthy status resulted in statistically higher risks of severe complications and limited recovery.

Conclusion

PCs changed clinical patterns and had critical roles in the survival outcomes of caustic injury victims. Clinical awareness achieves benefit by limiting injuries in mild cases or allowing emergent interventions in severe cases. Future studies based on worldwide populations are essential for realizing geographic differences.

Sarcopenia is a useful risk stratification tool to prognosticate splenic abscess patients in the emergency department

BACKGROUND/PURPOSE

Splenic abscess is a life-threatening surgical emergency which requires early diagnosis and intervention to maximize patient outcomes. This can be achieved through accurate risk stratification in the emergency department (ED). Sarcopenia refers to an age-related loss of skeletal muscle mass and strength that is accompanied by major physiologic and clinical ramifications, and often signifies decreased physiologic reserves. It is associated with poor clinical outcomes in sepsis, acute respiratory failure, oncological surgery, and liver transplantation. This study evaluates the utility of sarcopenia as a radiological stratification tool to predict in-hospital mortality of splenic abscess patients in the ED. This will assist emergency physicians, internists and surgeons in rapid risk stratification, assessing treatment options, and communicating with family members.

METHODS

99 adult patients at four training and research hospitals who had undergone an abdominal contrast computed tomography scan in the ED with the final diagnosis of splenic abscess from January 2004 to November 2017 were recruited. Evaluation for sarcopenia was performed via calculating the psoas cross-sectional area at the level of the third lumbar vertebra and normalising for height, before checking it against pre-defined values. Univariate analyses were used to evaluate the differences between survivors and non-survivors. Sensitivity, specificity, and predictive values of the presence of sarcopenia in predicting in-hospital mortality were calculated. Kaplan-Meier methods, log-rank test, and Cox proportional hazards model were also performed to examine survival between groups with sarcopenia versus non-sarcopenia.

RESULTS

Splenic abscess patients with sarcopenia were 7.56 times more at risk of in-hospital mortality than those without sarcopenia (multivariate-adjusted HR: 7.56; 95% CI: 1.55-36.93). Presence of sarcopenia was found to have 84.62% sensitivity and 96.49% negative predictive value in predicting mortality.

CONCLUSION

Sarcopenia is associated with poor prognoses of in-hospital mortality in patients with splenic abscess presenting to the ED. We recommend its use in the ED to rapidly risk stratify and predict outcome to guide treatment strategies.

Wound Infections of Snakebites from the Venomous Protobothrops mucrosquamatus and Viridovipera stejnegeri in Taiwan: Bacteriology, Antibiotic Susceptibility, and Predicting the Need for Antibiotics-A BITE Study

Snakebites from Taiwan habus (Protobothrops mucrosquamatus) and green bamboo vipers (Viridovipera stejnegeri) account for two-thirds of all venomous snakebites in Taiwan. While there has been ongoing optimization of antivenin therapy, the proper management of superimposed bacterial wound infections is not well studied. In this Bacteriology of Infections in Taiwanese snake Envenomation (BITE) study, we investigated the prevalence of wound infection, bacteriology, and corresponding antibiotic usage in patients presenting with snakebites from these two snakes. We further developed a BITE score to evaluate the probability of wound infections and guide antibiotic usage in this patient population. All snakebite victims who presented to the emergency departments of seven training and research hospitals and received at least one vial of freeze-dried hemorrhagic antivenin between January 2001 and January 2017 were identified. Patient biodata, laboratory investigation results, and treatment modalities were retrieved. We developed our BITE score via univariate and multiple logistic regression analyses. The receiver operating characteristic (ROC) curve was plotted to evaluate the predictive performance of the BITE score. Out of 8,295,497 emergency department visits, 726 patients presented with snakebites from a Taiwan habu or a green bamboo viper. The wound infection rate was 22.45%, with seven positive wound cultures, including six polymicrobial infections. Morganella morganii, Enterococcus spp., Bacteroides fragilis, and Aeromonas hydrophila were most frequently cultured. There were no positive blood cultures. A total of 33.0% (n = 106) of snakebite patients who received prophylactic antibiotics nevertheless developed wound infections, while 44.8% (n = 73) of wound infection patients were satisfactorily treated with one of the following antibiotics: amoxicillin/clavulanic acid, oxacillin, cefazolin, and ampicillin/sulbactam. With the addition of gentamicin, the success of antibiotic therapy increased by up to 66.54%. The prognostic factors for the secondary bacterial infection of snakebites were white blood cell counts, the neutrophil lymphocyte ratio, and the need for hospital admission. The area under the ROC curve for the BITE score was 0.839. At the optimal cut-off point of 5, the BITE score had a 79.58% accuracy, 82.31% sensitivity, and 79.71% specificity when predicting infection in snakebite patients. Our BITE score may help with antibiotic stewardship by guiding appropriate antibiotic use in patients presenting with snakebites. It may also be employed in further studies into antibiotic prophylaxis in snakebite patients for the prevention of superimposed bacterial wound infections.

Shock Index: A Simple and Effective Clinical Adjunct in Predicting 60-Day Mortality in Advanced Cancer Patients at the Emergency Department

Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.

Brain Computed Tomography in Stimulant Poisoning with Altered Consciousness

BACKGROUND

Stimulant poisoning frequently causes altered mental status (AMS) and can result in severe cerebral vascular complications. The role of noncontrast brain computed tomography (CT) in acute stimulant-poisoned patients presenting with AMS remains unclear.

OBJECTIVES

We examined the results and impacts of brain CT in acute stimulant-poisoned patients with AMS.

METHODS

We performed a retrospective single-center study that included all adult patients who presented to the emergency department with stimulant poisoning and AMS (Glasgow coma scale [GCS] score <15) between January 1, 2010 and December 31, 2017. Patients who had concomitant head trauma or who presented with focal neurologic symptoms were excluded. The primary outcome was the rate of acute abnormalities on brain CT. The secondary outcomes were to identify factors that affected the decision to perform brain CT in stimulant-poisoned patients with AMS and whether obtaining the brain CT scan itself affected the patients' prognoses.

RESULTS

The analysis included 66 patients, of whom 6 died from the poisoning. Noncontrast brain CT was performed in 31 patients and none had acute abnormalities. Patients who underwent brain CT were found to have worse GCS scores, higher body temperatures, higher intubation rates, higher admission rates, longer admission periods and intensive care unit stays, and a higher mortality rate. After adjusting for the propensity score, performing brain CT itself did not independently affect the patients' clinical outcomes.

CONCLUSIONS

Nontrauma stimulant-poisoned patients presenting with AMS and without focal neurologic symptoms were unlikely to have acute abnormalities on brain CT. Patients who underwent brain CT scans had worse consciousness and greater disease severity.

Traditional versus blended CPR training program: A randomized controlled non-inferiority study

Cardiopulmonary resuscitation (CPR) training and its quality are critical in improving the survival rate of cardiac arrest. This randomized controlled study investigated the efficacy of a newly developed CPR training program for the public in a Taiwanese setting. A total of 832 adults were randomized to either a traditional or blended (18-minute e-learning plus 30-minute hands-on) compression-only CPR training program. The primary outcome was compression depth. Secondary outcomes included CPR knowledge test, practical test, quality of CPR performance, and skill retention. The mean compression depth was 5.21 cm and 5.24 cm in the blended and traditional groups, respectively. The mean difference in compression depth between groups was -0.04 (95% confidence interval -0.13 to infinity), demonstrating that the blended CPR training program was non-inferior to the traditional CPR training program in compression depth after initial training. Secondary outcome results were comparable between groups. Although the mean compression depth and rate were guideline-compliant, only half of the compressions were delivered with adequate depth and rate in both groups. CPR knowledge and skill retained similarly in both groups at 6 and 12 months after training. The blended CPR training program was non-inferior to the traditional CPR training program. However, there is still room for improvement in optimizing initial skill performance as well as skill retention. Clinical Trial Registration: NCT03586752; www.clinicaltrial.gov.

Rapid responses in the emergency department of Linkou Chang Gung Memorial Hospital, Taiwan effectively prevent spread of COVID-19 among healthcare workers of emergency department during outbreak: Lessons learnt from SARS

Linkou Chang Gung Memorial Hospital, Taiwan has been on the forefront of efforts to manage and mitigate the Coronavirus Disease 2019 (COVID-19) pandemic since 20th January 2020. Despite having one of the largest and busiest emergency departments (EDs) in the world, we have managed to maintain a “zero-infection” rate among our ED healthcare workers through various systematic approaches. The measures implemented include establishing a clear flowchart with route planning, strict infection control policies and regulation of medical equipment, and team-based segregation in the workplace. These strategies, borne of our experience during the severe acute respiratory syndrome (SARS) outbreak, can complement a network of well-trained personnel to enable EDs around the world in successfully mounting an effective defense against new airborne illness while minimizing healthcare personnel casualties.

Prognostic accuracy of SIRS criteria and qSOFA score for in-hospital mortality among influenza patients in the emergency department

BACKGROUND

The seasonal influenza epidemic is an important public health issue worldwide. Early predictive identification of patients with potentially worse outcome is important in the emergency department (ED). Similarly as with bacterial infection, influenza can cause sepsis. This study was conducted to investigate the effectiveness of the Systemic Inflammatory Response Syndrome (SIRS) criteria and the quick Sequential Organ Failure Assessment (qSOFA) score as prognostic predictors for ED patients with influenza.

METHODS

This single-center, retrospective cohort study investigated data that was retrieved from a hospital-based research database. Adult ED patients (age ≥ 18 at admission) with laboratory-proven influenza from 2010 to 2016 were included for data analysis. The initial SIRS and qSOFA scores were both collected. The primary outcome was the utility of each score in the prediction of in-hospital mortality.

RESULTS

For the study period, 3561 patients met the study inclusion criteria. The overall in-hospital mortality was 2.7% (95 patients). When the qSOFA scores were 0, 1, 2, and 3, the percentages of in-hospital mortality were 0.6, 7.2, 15.9, and 25%, respectively. Accordingly, the odds ratios (ORs) were 7.72, 11.92, and 22.46, respectively. The sensitivity and specificity was 24 and 96.2%, respectively, when the qSOFA score was ≥2. However, the SIRS criteria showed no significant associations with the primary outcome. The area under the receiver operating characteristic curve (AUC) was 0.864, which is significantly higher than that with SIRS, where the AUC was 0.786 (P < 0.01).

CONCLUSIONS

The qSOFA score potentially is a useful prognostic predictor for influenza and could be applied in the ED as a risk stratification tool. However, qSOFA may not be a good screening tool for triage because of its poor sensitivity. The SIRS criteria showed poor predictive performance in influenza for mortality as an outcome. Further research is needed to determine the role of these predictive tools in influenza and in other viral infections.

Impact of Transport Time and Cardiac Arrest Centers on the Neurological Outcome After Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Study

Background

Should all out‐of‐hospital cardiac arrest (OHCA) patients be directly transported to cardiac arrest centers (CACs) remains under debate. Our study evaluated the impacts of different transport time and destination hospital on the outcomes of OHCA patients.

Methods and Results

Data were collected from 6655 OHCA patients recorded in the regional prospective OHCA registry database of Taoyuan City, Taiwan, between January 2012 and December 2016. Patients were matched on propensity score, which left 5156 patients, 2578 each in the CAC and non‐CAC groups. Transport time was dichotomized into <8 and ≥8 minutes. The relations between the transport time to CACs and good neurological outcome at discharge and survival to discharge were investigated. Of the 5156 patients, 4215 (81.7%) presented with nonshockable rhythms and 941 (18.3%) presented with shockable rhythms. Regardless of transport time, transportation to a CAC increased the likelihoods of survival to discharge (<8 minutes: adjusted odds ratio [aOR], 1.95; 95% CI, 1.11–3.41; ≥8 minutes: aOR, 1.92; 95% CI, 1.25–2.94) and good neurological outcome at discharge (<8 minutes: aOR, 2.70; 95% CI, 1.40–5.22; ≥8 minutes: aOR, 2.20; 95% CI, 1.29–3.75) in OHCA patients with shockable rhythms but not in patients with nonshockable rhythms.

Conclusions

OHCA patients with shockable rhythms transported to CACs demonstrated higher probabilities of survival to discharge and a good neurological outcome at discharge. Direct ambulance delivery to CACs should thus be considered, particularly when OHCA patients present with shockable rhythms.

Comparison between simple triage and rapid treatment and Taiwan Triage and Acuity Scale for the emergency department triage of victims following an earthquake-related mass casualty incident: a retrospective cohort study

BACKGROUND

Triage plays a crucial role in the emergency department (ED) management of mass casualty incidents (MCIs) when resources are limited. This study aimed to compare the performance of simple triage and rapid treatment (START) with that of the Taiwan Triage and Acuity Scale (TTAS) for the ED triage of victims following an earthquake-related MCI.

METHODS

We retrospectively reviewed the records of victims presenting at our ED with earthquake-related injuries within 24 h of a large-scale earthquake. TTAS was initially used at our ED for this event, and START was performed by retrospectively reviewing the patient records in a blinded manner. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START and TTAS were determined for predicting ED discharge.

RESULTS

We enrolled 105 patients (predominantly women, 60.0%; median age, 45.0 years) in this study; most of them presented with traumatic injuries and were initially triaged as TTAS level III (78.1%), followed by TTAS level II (11.4%). Although the majority of the victims (81.0%) were discharged, four deaths occurred. A moderate agreement in differentiating emergency from nonemergency patients was observed between START and TTAS. Furthermore, both the triage systems showed similar predictions for ED disposition (START AUC/sensitivity/specificity: 0.709/82.35%/55.00%; TTAS AUC/sensitivity/specificity: 0.709/90.59%/45.00%).

CONCLUSIONS

The present study demonstrated that START and TTAS have similar triage accuracy and ability to predict ED disposition. Our findings demonstrate that START may be used as an alternative to TTAS for the ED triage of victims following earthquake-related MCIs.

Evaluation of the Relationship Between Blood Pressure Control and Epistaxis Recurrence After Achieving Effective Hemostasis in the Emergency Department

BACKGROUND

Epistaxis is the most common cause of otorhinolaryngologic emergencies. There is a longstanding controversy regarding the relationship between epistaxis and hypertension (HTN), in terms of blood pressure (BP) control in the emergency department (ED) setting. The objective of this study is to evaluate the association between HTN, BP control, and recurrent epistaxis among patients initially admitted to the ED for epistaxis.

METHODS

This retrospective cohort study was conducted in the EDs of three different hospitals in Taiwan and included a total of 739 patients admitted for epistaxis.

RESULTS

Among ED patients with epistaxis, older age was significantly associated with a history of HTN, and a statistically significant difference in age was noted between groups classified according to the systolic BP/diastolic BP (SBP/DBP) at triage. Patients with a history of HTN had higher BP values at triage than did patients without a history of HTN (SBP: 175.68 ± 32.30 mmHg vs. 148.00 ± 26.26 mmHg, DBP: 95.04 ± 20.98 mmHg vs. 83.30 ± 16.65 mmHg; p < 0.0001). Antihypertensive medications were more commonly administered to patients with a history of HTN (p < 0.0001) and in those patients with SBP/DBP: ≥ 140/≥ 90 mmHg at triage (p < 0.0001). Among patients receiving antihypertensive medications, reductions in SBP by the time of discharge were significantly greater in patients with a history of HTN and in patients with SBP/DBP: ≥ 160/≥ 100 mmHg at triage. ED revisits due to recurrent epistaxis within 72 hours were significantly associated with male sex, a positive history of HTN, level of GOT, observation for recurrent epistaxis at ED, and duration of recurrent bleeding.

CONCLUSIONS

A positive history of HTN is related to recurrent epistaxis among ED patients. The effectiveness of administering antihypertensive agents before achieving hemostasis in patients admitted to the ED for epistaxis warrants further study.

Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention

Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. Criteria of assessment include in-hospital complications, length of stay, cost-effectiveness, and patient outcomes up to a year after discharge from hospital. A retrospective case-control study was done using data of 294 adult STEMI patients admitted to the emergency departments of two training and research hospitals and successfully underwent primary PCI from 1 January 2014 to 31 December 2015. Patients were followed up for a year post-discharge. Student t test and χ² test were done as univariate analysis to check for statistical significance of p < 0.05. Further regression analysis was done with respect to primary outcomes to adjust for major confounders. Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.

Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients' need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals' emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ² tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.

Brain computerized tomography reading in suspected acute ischemic stroke patients: what are essentials for medical students?

BACKGROUND

Few systematic methods prioritize the image education in medical students (MS). We hope to develop a checklist of brain computerized tomography (CT) reading in patients with suspected acute ischemic stroke (AIS) for MS and primary care (PC) physicians.

METHODS

Our pilot group generated the items indicating specific structures or signs for the checklist of brain CT reading in suspected AIS patients for MS and PC physicians. These items were used in a modified web-based Delphi process using the online software "SurveyMonkey". In total 15 panelists including neurologists, neurosurgeons, neuroradiologists, and emergency department physicians participated in the modified Delphi process. Each panelist was encouraged to express feedback, agreement or disagreement on the inclusion of each item using a 9-point Likert scale. Items with median scores of 7-9 were included in our final checklist.

RESULTS

Fifty-two items were initially provided for the first round of the Delphi process. Of these, 35 achieved general agreement of being an essential item for the MS and PC physicians. The other 17 of the 52 items in this round and another two added items suggested by the panelists were further rated in the next round. Finally, 38 items were included in the essential checklist items of brain CT reading in suspected AIS patients for MS and PC physicians.

CONCLUSIONS

We established a reference regarding the essential items of brain CT reading in suspected AIS patients. We hope this helps to minimize malpractice and a delayed diagnosis, and to improve competency-based medical education for MS and PC physicians.

Unilateral live twin tubal ectopic pregnancy presenting at 12 weeks of gestation: A case report

RATIONALE

Abdominal pain in pregnancy represents a demanding diagnostic challenge in the emergency department (ED) due to the extensive list of differential diagnoses to be considered, coupled with the possibility of each disease having nonclassical, atypical signs and symptoms, resultant from the patient's pregnant state. Additionally, emergency physicians (EPs) face limitations on investigative imaging modalities because of the need to minimize fetal radiation exposure. EPs have to tackle this diagnostic challenge while performing a balancing act to maximize both maternal and fetal outcomes in a time-sensitive manner, becauser any delays in decision-making at the ED may threaten the safety of mother and child. Two common causes of abdominal pain in pregnancy presenting to the ED are acute appendicitis and ectopic pregnancy. The latter is almost always diagnosed by 10 weeks of gestation. Here, we report an extremely rare case of unilateral live spontaneous twin tubal ectopic pregnancy presenting past 12 weeks of gestation, diagnosed after magnetic resonance imaging (MRI) of the abdomen.

PATIENT CONCERNS

A 37-year-old gravida 2 para 1 at 12 weeks and 6 days of gestation presented to our ED with a 2-day history of right iliac fossa pain, not associated with vaginal bleeding, fever, diarrhea, and vomiting. On examination, she was tachycardic (pulse rate 124 beats/min) and hypertensive (blood pressure 142/88 mm Hg). There was marked tenderness and guarding at the lower abdomen.

DIAGNOSES

Blood investigations were unremarkable, while abdominal ultrasonography found a live twin gestation with foetal heartbeats of 185 and 180 beats/min. MRI of the abdomen revealed an empty uterine cavity; 2 amniotic sacs and fetuses of diameter 10 cm, and a single placenta were noted in the right uterine adnexa. The patient was diagnosed with right live monochorionic diamniotic twin tubal pregnancy.

INTERVENTION

Our patient underwent emergency laparoscopic right salpingectomy.

OUTCOMES

The operation was successful and her postoperative care remained uneventful up to discharge.

LESSONS

Ectopic pregnancy cannot be ruled out based on prior normal antenatal examinations and gestational age of >10 weeks. EPs should not hesitate to order MRI scans for further evaluation if ultrasonography and laboratory findings are equivocal.

Impact of the caller’s emotional state and cooperation on out-of-hospital cardiac arrest recognition and dispatcher-assisted cardiopulmonary resuscitation

Objective

This study determined the impact of the caller’s emotional state and cooperation on out-of-hospital cardiac arrest (OHCA) recognition and dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) performance metrics.

Methods

This was a retrospective study using data from November 2015 to October 2016 from the emergency medical service dispatching centre in northern Taiwan. Audio recordings of callers contacting the centre regarding adult patients with non-traumatic OHCA were reviewed. The reviewers assigned an emotional content and cooperation score (ECCS) to the callers. ECCS 1–3 callers were graded as cooperative and ECCS 4–5 callers as uncooperative and highly emotional. The relation between ECCS and OHCA recognition, time to key events and DA-CPR delivery were investigated.

Results

Of the 367 cases, 336 (91.6%) callers were assigned ECCS 1–3 with a good inter-rater reliability (k=0.63). Dispatchers recognised OHCA in 251 (68.4%) cases. Compared with callers with ECCS 1, callers with ECCS 2 and 3 were more likely to give unambiguous responses about the patient’s breathing status (adjusted OR (AOR)=2.6, 95% CI 1.1 to 6.4), leading to a significantly higher rate of OHCA recognition (AOR=2.3, 95% CI 1.1 to 5.0). Thirty-one callers were rated uncooperative (ECCS 4–5) but had shorter median times to OHCA recognition and chest compression (29 and 122 s, respectively) compared with the cooperative caller group (38 and 170 s, respectively). Nevertheless, those with ECCS 4–5 had a significantly lower DA-CPR delivery rate (54.2% vs 85.9%) due to ‘caller refused’ or ‘overly distraught’ factors.

Conclusions

The caller’s high emotional state is not a barrier to OHCA recognition by dispatchers but may prevent delivery of DA-CPR instruction. However, DA-CPR instruction followed by first chest compression is possible despite the caller’s emotional state if dispatchers are able to skilfully reassure the emotional callers.

Deep vein thrombosis secondary to abdominal aortic aneurysm: A case report

RATIONALE

Abdominal aortic aneurysm is an extremely rare cause of deep vein thrombosis. Here we report an elderly gentleman who presented with deep vein thrombosis and was found to have concomitant abdominal aortic aneurysm upon ultrasonographic screening. It illustrates the possibility of such an aetiology, and the importance of screening for such aneurysms in a select patient population before heparinization.

PATIENT CONCERNS

A 73-year-old Asian gentleman with underlying hypertension, hyperlipidaemia, chronic renal failure, and history of chronic smoking presented to the emergency department with acute left lower limb swelling of 1 day. On examination, the patient was tachycardic (110 beats/minute) and hypertensive (168/84 millimeters mercury (mmHg)). The entire left lower limb was swollen with notable pitting oedema, tenderness, and warmth; left calf swelling was measured to be 4 centimeters (cm).

DIAGNOSES

The patient's Wells score of 4 placed him in the high-risk group for deep vein thrombosis. Serum D-dimer was subsequently found to be elevated at 926 nanograms/milliliter (ng/ml). Compression ultrasonography revealed a thrombus in the left deep femoral vein, confirming the diagnosis of deep vein thrombosis. The ultrasonographic evaluation was extended to the abdominal aorta due to the patient's high risk of abdominal aortic aneurysm, and a 7-cm aneurysm was indeed found. Further computed tomography and magnetic resonance imaging localized it to the infrarenal region, with left common iliac vein compression resulting in stagnant venous return.

INTERVENTIONS

Emergency endovascular repair was performed with insertion of an inferior vena cava filter.

OUTCOMES

The patient was subsequently monitored in the intensive care unit and uneventfully discharged after 2 weeks.

LESSONS

Such clinical presentations of deep vein thrombosis are rare, but physicians are reminded to consider screening for abdominal aneurysms and other anatomical causes before heparinization in patients who seemingly do not have thromboembolic risk factors. This is especially so for the high risk group of male deep vein thrombosis patients aged 65-75 years with a history of smoking who have yet to be screened for abdominal aortic aneurysms, in line with United States Preventive Services Task Force recommendations.

Hospital outcomes and cumulative burden from complications in type 2 diabetic sepsis patients: a cohort study using administrative and hospital-based databases

BACKGROUND

The association between type 2 diabetes and hospital outcomes of sepsis remains controversial when severity of diabetes is not taken into consideration. We examined this association using nationwide and hospital-based databases.

METHODS

The first part of this study was mainly conducted using a nationwide database, which included 1.6 million type 2 diabetic patients. The diabetic complication burden was evaluated using the adapted Diabetes Complications Severity Index score (aDCSI score). In the second part, we used laboratory data from a distinct hospital-based database to make comparisons using regression analyses.

RESULTS

The nationwide study included 19,719 type 2 diabetic sepsis patients and an equal number of nondiabetic sepsis patients. The diabetic sepsis patients had an increased odds ratio (OR) of 1.14 (95% confidence interval 1.1-1.19) for hospital mortality. The OR for mortality increased as the complication burden increased [aDCSI scores of 0, 1, 2, 3, 4, and ⩾5 with ORs of 0.91, 0.87, 1.14, 1.25, 1.56, and 1.77 for mortality, respectively (all p < 0.001)].The hospital-based database included 1054 diabetic sepsis patients. Initial blood glucose levels did not differ significantly between the surviving and deceased diabetic sepsis patients: 273.9 ± 180.3 versus 266.1 ± 200.2 mg/dl (p = 0.095). Moreover, the surviving diabetic sepsis patients did not have lower glycated hemoglobin (HbA1c; %) values than the deceased patients: 8.4 ± 2.6 versus 8.0 ± 2.5 (p = 0.078).

CONCLUSIONS

For type 2 diabetic sepsis patients, the diabetes-related complication burden was the major determinant of hospital mortality rather than diabetes per se, HbA1c level, or initial blood glucose level.

Introduction of a mass burn casualty triage system in a hospital during a powder explosion disaster: a retrospective cohort study

Background

The triage system used during an actual mass burn casualty (MBC) incident is a major focus of concern. This study introduces a MBC triage system that was used by a burn center during an actual MBC incident following a powder explosion in New Taipei City, Taiwan.

Methods

This study retrospectively analyzed data from patients who were sent to the study hospital during a MBC incident. The patient list was retrieved from a national online management system. A MBC triage system was developed at the study hospital using the following modifiers: consciousness, breathing, and burn size. Medical records were retrieved from electronic records for analysis. Patient outcomes consisted of emergency department (ED) disposition and intervention.

Results

The patient population was predominantly female (56.3%), with an average age of 24.9 years. Mean burn sizes relative to the TBSA of triage level I, II, and III patients were 57.9%, 40.5%, and 8.7%, respectively. ICU length of stay differed markedly according to triage level (mean days for levels I vs II vs III: 57.9 vs 39.9 vs 2.5 days; p < 0.001). Triage system levels I and II indicate ICU admission with a sensitivity of 93.9% (95%CI 80.4-98.3%) and a specificity of 86.7% (62.1-96.3%).Overall, 3 (6.3%) patients were under-triaged. Two (4.2%) patients were over-triaged. Sixteen (48.5%) and 21 (63.6%) patients of triage levels I and II received endotracheal intubation and central venous catheterization, respectively. Sorting of the study population with simple triage and rapid treatment (START) showed great sensitivity (100.0%) but poor specificity (53.3%). The Taiwan Triage and Acuity Scale (TTAS) presented 87.9% sensitivity and 93.9% specificity.

Conclusions

The current MBC triage algorithm served as a good indicator of ED disposition but might have raised excessive immediate attention and had the potential to exhaust the available resources. These findings add to our knowledge of the MBC triage system and should help future researchers in adjusting the triage criteria to fit actual disasters.

Euglycemic diabetic ketoacidosis caused by dapagliflozin: A case report

RATIONALE

Diabetic ketoacidosis is a serious and potentially life-threatening acute complication of diabetes mellitus (DM). Euglycemic diabetic ketoacidosis (eDKA) is however challenging to identify in the emergency department (ED) due to absence of marked hyperglycemia, often leading to delayed diagnosis and treatment. eDKA has been recently found to be associated with sodium-glucose cotransporter 2 (SGLT2) inhibitors, one of the newest classes of antidiabetics, though there are very limited reports implicating dapagliflozin as the offending agent in ED patients. Here we report a type 2 diabetic patient who presented to the ED with eDKA secondary to dapagliflozin administration.

PATIENT CONCERNS

A 61-year-old Asian female with underlying type 2 DM presented to our ED with body weakness, dyspnea, nausea, vomiting, and mild abdominal pain for the past 2 days. These symptoms were preceded by poor oral intake for 1 week due to severe toothache. Dapagliflozin was recently added to her antidiabetic drug regimen of metformin and glibenclamide 2 weeks ago.

DIAGNOSES

Arterial blood gases showed a picture of severe metabolic acidosis with an elevated anion gap, while ketones were elevated in blood and positive in urine. Blood glucose was mildly elevated at 180 mg/dL. Serum lactate levels were normal. Our patient was thus diagnosed with eDKA.

INTERVENTION

Our patient was promptly admitted to the intensive care unit and treated for eDKA through intravenous rehydration therapy with insulin infusion.

OUTCOMES

Serial blood gas analyses showed gradual resolution of the patient's ketoacidosis with normalized anion gap and clearance of serum ketones. She was discharged uneventfully on day 4, with permanent cessation of dapagliflozin administration.

LESSONS

Life-threatening eDKA as a complication of dapagliflozin is a challenging and easilymissed diagnosis in the ED. Such an ED presentation is very rare, nevertheless emergency physicians are reminded to consider the diagnosis of eDKA in a patient whose drug regimen includes any SGLT2 inhibitor, especially if the patient presents with nausea, vomiting, abdominal pain, dyspnea, lethargy, and is clinically dehydrated. These patients should then be investigated with ketone studies and blood gas analyses regardless of blood glucose levels for prompt diagnosis and treatment.

One-year survival rate and healthcare costs after cardiac arrest in Taiwan, 2006-2012

OBJECTIVES

The annual increase in costs and the quality of life of survivors of cardiac arrest are major concerns. This study used National Health Insurance Research Database (NHIRD) of Taiwan to evaluate the 1-year survival rate and the annual healthcare costs of survivors after cardiac arrest.

METHODS

This retrospective, fixed-cohort study conducted from 2006 to 2012, involved 2 million individuals randomly selected from the NHIRD of Taiwan. Adult patients at least 18 years old who were diagnosed with cardiac arrest were enrolled. Survival was followed up for 1 year.

RESULTS

In total, 2,256 patients were enrolled. The survivor cohort accounted for 4% (89/2256) of the study population. There were no significant differences in the demographic characteristics of the survival and non-survival cohorts, with the exceptions of gender (male: survival vs. non-survival, 50.6% vs. 64.5%, p = 0.007), diabetes mellitus (49.4% vs. 35.8%, p = 0.009), and acute coronary syndrome (44.9% vs. 31.9%, p = 0.010). Only 38 (1.7%) patients survived for > 1 year. The mean re-admission to hospital during the 1-year follow up was 73.5 (SD: 110.2) days. The mean healthcare cost during the 1-year follow up was $12,953. Factors associated with total healthcare costs during the 1-year follow up were as follows: city or county of residence, being widowed, and Chronic Obstructive Pulmonary Disease (city or county of residence, β: -23,604, p < 0.001; being widowed, β: 25,588, p = 0.049; COPD, β: 14,438, p = 0.024).

CONCLUSIONS

There was a great burden of the annual healthcare costs of survivors of cardiac arrest. Socioeconomic status and comorbidity were major confounders of costs. The outcome measures of cardiac arrest should extend beyond the death, and encompass destitution. These findings add to our knowledge of the health economics and indicate future research about healthcare of cardiac arrest survivors.

Celebrating the 20th Anniversary of Emergency Medicine Specialty in Taiwan

The year 2018 marks the 20th anniversary of emergency medicine (EM) as a medical specialty in Taiwan. Within the past two decades, Taiwan EM specialists have achieved numerous significant milestones in the development of the specialty in Taiwan, as described in this paper. The themes emerging from this paper assist in understanding the characteristics of Taiwan EM specialty, and may serve as a guiding model for other countries where the EM specialty is undergoing a similar process of development and optimization.

Effectiveness of hands-on cardiopulmonary resuscitation practice with self-debriefing for healthcare providers: A simulation-based controlled trial

Introduction:

The psychomotor skill of cardiopulmonary resuscitation emphasized the importance of high-quality chest compression. This investigation examined the effect of self-debriefing and the different materials of debriefing during hands-on cardiopulmonary resuscitation practice for healthcare providers.

Methods:

This was a randomized controlled trial of a cardiopulmonary resuscitation training program involving emergency medical technicians in northern Taiwan. Participants were blinded to the study purpose and were allocated randomly using the black envelope method. All participants completed a 2-min pre-test of hands-only cardiopulmonary resuscitation using a manikin. Those who were allocated to the control group received self-debriefing with knowledge of pre-test result. Those who were allocated to the experimental group received self-debriefing with an additional biomechanical information of performance of chest compression. A post-test was performed 30 min after the pre-test.

Results:

A total of 88 participants were enrolled with 44 in each group. There was significant difference of cardiopulmonary resuscitation quality after self-debriefing among all participants (pre- vs post-test adequate rate, 54.7% vs 67.5%, p = 0.028; adequate depth, 41.2% vs 69.5%, p < 0.001; full recoil, 35.9% vs 54.5%, p = 0.001). The analysis of effects of self-debriefing with additional knowledge of performance revealed no significant difference in any of the measurements (improvement in adequate rate, 11.3% vs 14.2%, p = 0.767; adequate depth, 29.6% vs 27.0%, p = 0.784; full recoil, 23.0% vs 14.1%, p = 0.275).

Conclusion:

Self-debriefing improved hands-only cardiopulmonary resuscitation quality whether or not biomechanical information of performance of chest compression was given.

Comparison of the Mortality in Emergency Department Sepsis Score, Modified Early Warning Score, Rapid Emergency Medicine Score and Rapid Acute Physiology Score for predicting the outcomes of adult splenic abscess patients in the emergency department

Background

Splenic abscess is rare but has mortality rates as high as 14% even with recent improvements in management. Early and appropriate intervention may improve patient outcomes, yet at present there is no identified method that can predict mortality risk rapidly and accurately for emergency physicians, surgeons, and intensivists to decide on the ideal course of action.

Objective

This study aims to evaluate the performance of Mortality in Emergency Department Sepsis Score (MEDS), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) for predicting the mortality risk of adult splenic abscess patients. This will expedite decision making in the emergency department (ED) to increase survival rates and help avoid unnecessary splenectomies.

Methods

Data of 114 adult patients admitted to the EDs of 4 research and training hospitals who had undergone an abdominal contrast CT scan and diagnosed with splenic abscess between Jan 2000 and April 2015 were analyzed. The MEDS, MEWS, REMS, and RAPS and their corresponding mortality risks were calculated, with their abilities to predict patient mortality assessed through receiver operating characteristic curve analysis and calibration analysis.

Results

MEDS was found to be the best performing scoring system across all indicators, with sensitivity, specificity, and accuracy of 92.86%, 88.00%, and 88.60% respectively; its area under curve for AUROC analysis was 0.92. With a cutoff value of 8, negative predictive value of MEDS was 98.88%.

Conclusion

Our series is the largest multicenter study in adult ED patients with splenic abscess. The results from the present study show that MEDS is superior to MEWS, REMS and RAPS in predicting mortality, thus allowing earlier detection of critically ill adult ED splenic abscess patients. Therefore, we recommend that MEDS be used for predicting severity of illness and risk stratification in these patients.

Rapid Emergency Medicine Score: A novel prognostic tool for predicting the outcomes of adult patients with hepatic portal venous gas in the emergency department

Objective

This study aims to evaluate the performance of Rapid Emergency Medicine Score (REMS), Rapid Acute Physiology Score (RAPS), and Modified Early Warning Score (MEWS) in ascertaining the severity of illness and predicting the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians (EPs) in risk stratification.

Methods

Data for 66 adult HPVG patients who visited the EDs of 2 research hospitals between October 1999 and April 2016 were analyzed. REMS, RAPS, and MEWS were calculated based on data in the ED, and probability of death was calculated for each patient based on these scores. The ability of REMS, RAPS, and MEWS to predict group mortality was assessed by using receiver operating characteristic (ROC) curve analysis and calibration analysis.

Results

The sensitivity, specificity, and accuracy for each scoring system were 92.1%, 89.3%, and 90.9% for REMS, 86.8%, 82.1%, and 84.8% for RAPS, and 78.9%, 89.3%, and 83.3% for MEWS respectively. In the ROC curve analysis, the areas under the curve for REMS, RAPS, and MEWS were 0.929, 0.877, and 0.856 respectively.

Conclusion

Our study is the largest series performed in a population of adult HPVG patients in the ED. The results from this study demonstrate that REMS is superior in predicting the mortality of these patients compared to RAPS and MEWS. We therefore recommend that REMS be used for outcome prediction and risk stratification of adult HPVG in the ED.

Improved thrombolytic effect with focused ultrasound and neuroprotective agent against acute carotid artery thrombosis in rat

Combination therapy with focused ultrasound (FUS) and a neuroprotective agent, BNG-1, was examined in an acute carotid thrombotic occlusion model using LED irradiation in rat to improve the thrombolytic effect of rt-PA. Seven treatment groups included (A) intravenous bolus injection of 0.45 mg/kg rt-PA, (B) intravenous bolus injection of 0.9 mg/kg, (C) sonothrombolysis with FUS alone, (D) oral administration of 2 g/kg BNG-1 for 7 days alone, (E) A + D, (F) A + C, and (G) A + C + D. Four comparison groups were made including (H) 0.45 mg/kg rt-PA 20% bolus +80% IV fusion + FUS, (I) 0.9 mg/kg rt-PA with 10% bolus + 90% intravenous fusion, (J) B + C, (K) B + D. At 7 days after carotid occlusion, small-animal carotid ultrasound and 7 T MR angiography showed the recanalization rate of ≤50% stenosis was 50% in group B and 83% in group I, but 0% in groups A and C and 17% in group D. Combination therapy improved recanalization rate to 50–63% in groups E and F, to 67–83% in groups J and K, and to 100% in groups G and H. Our study demonstrated combination therapy with different remedies can be a feasible strategy to improve the thrombolytic effect of rt-PA.

Fatal cardiac glycoside poisoning due to mistaking foxglove for comfrey

CONTEXT

Accidental ingestion of foxglove (Digitalis purpurea) can cause significant cardiac toxicity. We report a patient who ingested foxglove mistaking it for comfrey and developed refractory ventricular arrhythmias. The patient died despite treatment with digoxin-specific antibody fragments (DSFab) and veno-arterial extracorporeal membrane oxygenation (VA-ECMO).

CASE DETAILS

A 55-year-old woman presented to the emergency department with nausea, vomiting and generalized weakness eight hours after drinking "comfrey" tea. She had bradycardia (54 beats/min) and hyperkalemia (7.6 mEq/L). Electrocardiogram revealed a first-degree atrioventricular conduction block with premature atrial contractions, followed by polymorphic ventricular tachycardia three hours after arrival. A serum digoxin level was 151.2 ng/mL. The patient developed ventricular fibrillation while waiting for Digibind infusion. Resuscitation was performed and an emergent VA-ECMO was set up. A total of eight vials of Digibind were given over the next 16 hours. She temporarily regained consciousness, but remained hemodynamically unstable and subsequently developed lower limb ischemia and multiple organ failure, and she expired on hospital day seven. A botanist confirmed that the plant was foxglove.

CONCLUSIONS

The diagnosis of cardiac glycoside plant poisoning can be difficult in the absence of an accurate exposure history. In facilities where DSFab is unavailable or insufficient, early VA-ECMO might be considered in severely cardiotoxic patients unresponsive to conventional therapy.