Background:Acute appendicitis is the most common surgical etiology for acute abdominal pain in children. In this study, we examine whether there is a correlation between the intensity of abdominal pain, measured by the Visual Analogue Scale (VAS), and acute appendicitis. Understanding this correlation can facilitate timely diagnosis of acute appendicitis. Methods:We retrospectively reviewed 12,545 cases of children aged 3-18 years who were admitted to the pediatric Emergency Department of University Medical Center between January 2015 and December 2020 with acute abdominal pain (≤ 7 days). A final diagnosis of acute appendicitis was determined in 1,401 patients (15.1%). Of these patients, 1,123 (80.1%) underwent appendectomy and 353 (25.0%) had complicated appendicitis. Results:The results demonstrate significantly higher initial VAS scores in acute appendicitis patients compared to patients with abdominal pain from other etiologies. In addition, being young, male, and Jewish were all found to correlate with a reduced likelihood of acute appendicitis diagnosis in the study cohort. After adjusting for age, sex, and ethnicity, higher initial pain levels were positively correlated with the likelihood of an appendicitis diagnosis. Conclusion:The degree of abdominal pain can serve as a valuable clinical marker for healthcare practitioners in assessing the likelihood of acute appendicitis. This tool can enhance the accuracy of current clinical scoring systems, thereby reducing the rate of appendicitis misdiagnosis and complications.
Cartap hydrochloride (CH) is a Class II hazardous pesticide that causes toxicity by inhibiting post-synaptic nicotinic acetylcholine receptors and affecting calcium release in the sarcoplasmic reticulum. While mortality is generally low, severe cases can lead to respiratory failure. A 25-year-old male presented to the emergency department six hours after intentionally consuming approximately 12 g of 50% CH. He exhibited vomiting, drowsiness (Glasgow Coma Score [GCS]: 13/15), and bradycardia (HR: 52/min). Initial arterial blood gas (ABG) analysis revealed mixed acidosis (pH: 7.296, pCO2: 60.8, pO2: 102.8, Lactate: 4.2, and HCO3: 20.3). Notably, serum pseudo-cholinesterase levels and other laboratory findings were within normal limits. The patient was treated with non-invasive ventilation (NIV) for respiratory acidosis and administered a loading dose of N-acetylcysteine (NAC) (150 mg/kg) along with symptomatic management. His sensorium and ABG parameters normalized within six hours of treatment. He remained asymptomatic and was discharged after three days. Human toxicity from CH is rarely reported, and cases involving mixed acidosis are particularly sparse in literature. This case highlights the importance of recognizing CH poisoning, which can mimic organophosphate toxicity. Vigilant monitoring for acidosis via ABG and early intervention with NAC and supportive care, such as NIV, are crucial for successful clinical outcomes.
Background:Prehospital drug administration is crucial for improving resuscitation efforts in emergency departments (EDs) and enhancing survival rates for out-of-hospital cardiac arrest (OHCA) patients. While evidence supports the prehospital use of life-saving medications like epinephrine, the effects of prehospital vascular access routes remain under-researched. This study collects two years of data on adult patients with non-traumatic OHCA transported by Taoyuan Emergency Medical Services (EMS), aiming to evaluate how prehospital vascular access impacts resuscitation success and survival outcomes. Methods:This was a retrospective study conducted by the Taoyuan Fire Department and Taoyuan General Hospital. Data were collected from January 1, 2023 to September 30, 2024. The inclusion criteria consisted of adult patients experiencing non-traumatic OHCA who had established vascular access at the scene. Exclusion criteria were those with missing data and EMS-witnessed OHCA enroute. The outcome measurements aimed to assess whether establishing vascular access from prehospital improves the efficiency of epinephrine administration in the ED and enhances survival rates among OHCA patients. Data were collected using the Electronic Patient Care Report. Results:A total of 185 cases were included in the analysis, consisting of 97 males (52.4%) and 88 females (47.6%), with an average age of 71 years. When comparing the 95 cases with vascular access to the 90 cases without vascular access, the overall time from arrival in the emergency room to the administration of epinephrine was significantly shorter for those with vascular access, averaging 2 minutes compared to 4 minutes for those without (p < 0.001). Additionally, the cumulative time-event analysis using the Kaplan-Meier method showed a significant reduction in the time to epinephrine administration (p < 0.001). Conclusion:Establishing prehospital vascular access significantly enhances ED resuscitation efficiency in non-traumatic OHCA. These findings support integrating vascular access protocols into prehospital care practices to improve outcomes for cardiac arrest.
Free Open Access Medical Education (FOAMed) has rapidly transformed emergency medicine learning by offering accessible, on-demand educational resources such as blogs, podcasts, and social media content. However, for physicians, the vast and unregulated nature of FOAMed may be overwhelming and difficult to navigate. This brief report introduces FOAMed as a movement, outlines high-quality starting points for newcomers, and offers guidance on evaluating educational quality and managing conflicting information. By critically engaging with FOAMed and applying it critically and appropriately in clinical contexts, emergency physicians can enhance their ongoing education and professional development.
A 65-year-old male presented to the emergency department with acute dyspnea and critically low oxygen saturation (77%), which led to the discovery of an unusual pulmonary arteriovenous malformation (PAVM). Computed tomographic pulmonary angiography revealed a 2.5-cm vascular lesion connecting the right inferior pulmonary artery to the left cardiac atrium, resulting in significant right-to-left shunting. The patient's respiratory symptoms resolved completely after video-assisted thoracoscopic surgical resection, demonstrating the value of comprehensive imaging in diagnosing rare vascular anomalies. This case highlights the clinical significance of unexpected vascular malformations in older adults.
Ectopic pregnancy (EP) is a commonly seen, potentially life-threatening condition that can be challenging to diagnose in the emergency department (ED) setting. A retroperitoneal EP is an extremely rare condition, with a limited number of reported cases. Because of this, many emergency medicine physicians may not be familiar with presenting symptoms of a retroperitoneal EP. Rupture of an EP is a life-threatening complication that must be diagnosed quickly to reduce the risk of mortality. We present a 27-year-old female who presented with a two-day history of progressive right lower quadrant abdominal pain, nausea, and vomiting. ED evaluation revealed tachycardia of 140 beats per minute, and laboratory assessment was positive for leukocytosis of 27,030 k/uL and a positive qualitative human chorionic gonadotropin. The initial concern was for appendicitis versus ruptured ectopic pregnancy. Point-of-care ultrasound was negative for both intrauterine pregnancy and intraperitoneal fluid. However, there were heterogeneous contents within the pelvis of unclear etiology. Obstetrics was consulted, admitted the patient, and obtained a formal abdominal ultrasound to evaluate her appendix. The radiologist reported a 12 cm pelvic mass for which the differential diagnosis included a uterine fibroid, ectopic pregnancy, or appendicitis. The patient was taken to the operating room for a diagnostic laparoscopy and laparotomy and was diagnosed with a ruptured retroperitoneal EP. She underwent evacuation of the retroperitoneal hematoma and right salpingo-oophorectomy. She was discharged home on postoperative day four.
Acute barium poisoning, though rare, can cause severe hypokalemia, respiratory paralysis, and life-threatening arrhythmias. Conventional treatments, including potassium replacement, may not rapidly resolve severe toxicity. Extracorporeal removal therapies (ECT), such as hemodialysis (HD) and continuous renal replacement therapy (CRRT), have been used to accelerate barium elimination, but their overall clinical outcomes remain unclear. This scoping review systematically summarizes current literature on the clinical outcomes of ECT in acute barium poisoning. We searched Embase, Ovid MEDLINE, and Cochrane Trials databases up to November 30, 2024. Fourteen articles reporting 15 cases were included. Most cases involved intentional oral ingestion, predominantly with barium chloride. Severe hypokalemia, respiratory paralysis, and serious arrhythmia were common. The overall survival rate was high (93.3%), with only one reported mortality. Toxicokinetic data showed that HD significantly reduced the elimination half-life of barium compared to non-dialysis approaches, while CRRT provided slower but sustained toxin removal. No ECT-related adverse events were reported. The findings highlight ECT as an effective method to manage severe barium poisoning symptoms. However, limited case data and publication bias indicate a need for larger comparative studies to determine optimal extracorporeal therapy strategies.
Background: In Japan, few hospitals have emergency physicians who handle all diseases and trauma, regardless of their specialty, and emergency physicians have to work in a variety of settings. The Emergency Medicine Alliance (EMA) was formed in 2009 to address this gap and enhance emergency room-type (ER-type) emergency medicine, where emergency specialists manage all diseases and trauma akin to the approach in the United States. We aimed to examine the EMA's activities, impact, and contributions over the past 15 years. Methods: This descriptive study reviewed the EMA's activities and outcomes from its inception in 2009 to 2024. The EMA is a nonprofit organization in Japan that includes 76 physicians and over 4,400 mailing list participants. Data from the EMA's internal records and publications were analyzed using descriptive statistics and qualitative feedback. Results: The EMA's mission includes developing ER-type emergency medicine, establishing professional identity, supporting networking, providing educational resources, and promoting research. The EMA has successfully increased its mailing list to over 4,200 by 2023 and transitioned to a nonprofit in 2016. It published four books and one journal, created the Choosing Wisely index, and conducted several educational workshops, including 20 EMA meetings and 10 director academies. The EMA's initiatives significantly contributed to the recognition of emergency physicians in Japan. The EMA has also focused on awareness activities, such as surveying burnout among emergency physicians and publishing the results of these surveys. Conclusions: The EMA has contributed to the advancement of emergency medicine in Japan by establishing a robust network, providing comprehensive educational resources, and advocating for the professional status of emergency physicians. Continued support and innovative strategies are essential to sustaining these achievements and addressing future challenges in emergency medical care.
Background:The ongoing COVID-19 pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has led to significant morbidity and mortality worldwide. Identifying the clinical features and factors influencing severe disease and mortality in individuals hospitalized with COVID-19 is essential for informing clinical management strategies and optimizing healthcare resource distribution. Methods:We conducted a retrospective cohort study of 684 patients hospitalized with COVID-19 at a single center in Taiwan between April and June 2022. Demographic characteristics, comorbidities, vaccination status, and clinical outcomes were compared among different age groups (< 50 years, 50-74 years, and ≥ 75 years). Logistic regression analyses were performed to identify factors associated with critical illness and mortality. Results:The median age of the cohort was 72 years (interquartile range [IQR]: 58-82), and 59.6% were male. Older patients had a significantly higher prevalence of comorbidities. The overall rates of mortality and critical illness were 15.1% and 30.4%, respectively. There were no significant differences in the occurrence of critical illness among the age groups. However, mortality was significantly higher in patients aged ≥ 50 years. In the multivariate analysis, oral antiviral drug use (adjusted odds ratio [aOR]: 0.5, 95% CI [confidence interval]: 0.3-0.7) and being fully vaccinated (aOR: 0.6, 95% CI: 0.4-0.8) were associated with lower mortality, while having ≥ 3 risk factors (aOR: 1.9, 95% CI: 1.2-3.0) was associated with higher mortality. Additionally, age ≥ 50 years was associated with increased mortality; 50-74 years (aOR: 2.3, 95% CI: 1.1-4.8); ≥ 75 years (aOR: 2.3, 95% CI: 1.1-4.8) compared to age < 50 years. Similar factors were associated with critical illness. Conclusions:Older age was associated with higher mortality but not with an increased risk of critical illness in patients hospitalized with COVID-19. Oral antiviral drug use and being fully vaccinated were associated with better outcomes, highlighting the importance of early treatment and vaccination in mitigating severe COVID-19.
Background:Brugada syndrome is a rare cardiac condition associated with an increased risk of ventricular arrhythmias and sudden cardiac death. Fever is a recognized trigger that can unmask Brugada patterns on electrocardiography (ECG), yet fever-induced Brugada syndrome remains uncommon and is often underdiagnosed. Case Presentation:We report the case of a 72-year-old man who presented to the emergency department with intermittent fever and lower back pain. Eight hours after admission, during a febrile episode with a body temperature of 39°C, the patient developed chest tightness. ECG revealed ST-segment elevation and an rSR' pattern in leads V1 and V2, consistent with a Type 1 Brugada pattern. Emergent coronary angiography showed normal coronary arteries. With the resolution of fever, the patient's symptoms subsided, and subsequent ECGs returned to normal sinus rhythm. He remained asymptomatic throughout his hospital course and follow-up. Conclusions:This case highlights the diagnostic challenge of fever-induced Brugada syndrome, which can mimic acute coronary syndromes. Prompt recognition and appropriate evaluation are essential to prevent misdiagnosis and optimize patient outcomes. Further studies are needed to clarify the prevalence and clinical significance of fever-induced Brugada patterns in diverse populations.
Pneumocystis jirovecii pneumonia (PJP) is a life-threatening opportunistic infection that primarily affects immunocompromised individuals, particularly those with acquired immunodeficiency syndrome caused by human immunodeficiency virus (HIV). The clinical presentation of PJP can be atypical, with symptoms such as spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema, complicating diagnosis. In this report, we present a case of a 31-year-old male pharmacist with newly diagnosed HIV and PJP, who presented with persistent cough, dyspnea, intermittent fever, and subcutaneous emphysema. Chest X-ray and CT scans revealed bilateral ground-glass opacities, pneumomediastinum, and subcutaneous emphysema. The patient was diagnosed with HIV and PJP based on clinical findings and laboratory tests. Treatment with levofloxacin, penicillin, Caspofungin, and antiretroviral therapy led to significant improvement. This case highlights the importance of early diagnosis and the need for heightened clinical awareness of PJP in HIV-positive patients presenting with respiratory symptoms, particularly when imaging reveals atypical features.
Background: Point-of-care ultrasound (PoCUS) has become a crucial tool in the emergency department, aiding in rapid patient assessment and diagnosis, particularly in cases of acute dyspnea, which can have life-threatening causes. This study explores the diagnostic accuracy of PoCUS performed by emergency medicine residents, utilizing visual estimation and E-Point Septal Separation (EPSS) methods, in comparison to conventional 2D echocardiograms interpreted by sonographers. Methods: A total of 112 adult patients with acute dyspnea were included in this non-inferiority study. Visual estimation and EPSS measurements were performed by trained emergency medicine residents, with the results compared to 2D echocardiograms for sensitivity, specificity, positive and negative predictive values, likelihood ratios, receiver operating characteristic curve and diagnostic accuracy. Results: The study demonstrated a moderate positive correlation between visual estimation and EPSS methods and 2D echocardiography findings, with a Spearman's correlation coefficient of 0.422 and 0.411, respectively. The visual estimation method showed higher positive likelihood ratios (107) and sensitivity (100%) for detecting severely reduced ejection fraction (EF) < 30%, while EPSS displayed slightly lower positive likelihood ratios (13.4) and sensitivity (100%) in the same category. The diagnostic accuracy for both methods was highest in patients with severely depressed EF and lowest in those with moderately depressed EF. The study revealed some discrepancies in classification between methods, with visual estimation and EPSS sometimes underestimating or overestimating EF, potentially due to patient factors and operator-dependent bias. Conclusion: This study demonstrates that visual estimation and EPSS methods, when performed by emergency medicine residents, exhibit a moderate positive correlation with 2D echocardiography findings. These methods offer a statistically significant diagnostic accuracy in estimating left ventricular ejection fraction, making them valuable tools for initial assessment in time-sensitive situations.
Background: Rhabdomyolysis is a condition caused by the breakdown of skeletal muscles, leading to the release of intracellular contents. It is characterised by the triad of myalgia, muscle weakness and myoglobinuria. Traditionally, patients with this condition are hospitalized for intravenous hydration and monitoring. The objective of our study is to determine alternative safe disposition options for this condition. Method: We conducted a retrospective observational study of 90 patients with exertional rhabdomyolysis admitted to an acute short stay ward (under 24 hours) through the Emergency Department (ED) of a tertiary restructured hospital between December 2020 and January 2022. Rhabdomyolysis was defined as a creatine kinase (CK) level > 1,000 U/L. Data collected included the presence of risk factors, symptoms, and laboratory values at presentation. Outcomes included time to downtrend of CK count, new-onset renal function impairment, and duration to renal function impairment (if present). Results: The majority of our study cohort were young and female (60/90, 67%), with a median age of 26 years. Most patients presented to the ED within 3 days of the triggering event (median: 3, interquartile range [IQR]: 2-3). All patients experienced muscle pain (90/90, 100%). At presentation, their potassium levels were normal (90/90, 100%; median: 4.0, IQR: 3.7-4.2). The majority had CK levels of > 20,000 U/L (82/90, 91%), abnormal liver function (90/90, 100%) and renal impairment (1/90, 1%). During admission to the short stay ward, one additional patient developed renal function impairment. CK peaked on days 4-5 after the triggering event, with a median downtrend time of 6 days (IQR: 5-9). Conclusion: Patients with exertional rhabdomyolysis who have no risk factors and can maintain oral hydration can be managed in an ambulatory setting with regular follow-up. This disposition can reduce the use of hospital resources.
Background: Lumbar puncture (LP) is a common diagnostic procedure in the emergency department (ED). Post-dural puncture headache (PDPH) is the most frequent complication following LP. Despite evidence suggesting that strict bed rest does not prevent PDPH, patients in Taiwan are often required to remain in a supine position for 6 to 8 hours post-LP, leading to prolonged ED stays. This study aims to evaluate the impact of strict bed rest on the incidence of PDPH and ED length of stay (LOS). Methods: A retrospective cohort study was conducted at a medical center in central Taiwan, involving all adult ED patients who underwent LP from September 1, 2023, to March 31, 2024. Emergency specialists determined the need for strict bed rest based on individual patient conditions. Nurse practitioners recorded the occurrence of PDPH and ED LOS. Patients with incomplete data were excluded. Results: Out of 76,691 adult ED patients, 143 patients underwent LP, with 141 patients included in the final analysis. Among 68 assessable patients, 52 patients did not rest supine and 16 patients did, showing no significant difference in PDPH occurrence (p = 0.634). Overall, 55 patients did not rest supine, and 86 patients did, with significant differences in ED LOS: 9 hours for non-supine rest versus 19 hours for Conclusion: Reducing routine post-LP bed rest does not increase the risk of PDPH and might reduce LOS in the ED.
Neurogenic pulmonary edema (NPE) is a rare, life-threatening condition characterized by the accumulation of fluid in the lungs following acute central nervous system (CNS) injury. This case report discusses a 42-year-old woman who presented to the emergency department with sudden onset of severe headache followed by syncope. She was later found unconscious and experienced multiple episodes of seizures and respiratory distress. Initial chest X-ray (CXR) revealed clear lung fields, but two hours later, bilateral alveolar opacities indicative of pulmonary edema were noted. Brain computed tomography (CT) confirmed the presence of subarachnoid hemorrhage (SAH). NPE typically presents with symptoms similar to other causes of pulmonary edema, including dyspnea, frothy sputum, and wheezing. It often follows conditions such as epileptic seizures, traumatic brain injury, or intracranial hemorrhage. In this case, a significant amount of frothy sputum was observed during endotracheal intubation, further supporting the diagnosis of NPE. The primary focus of treatment for NPE involves managing the underlying CNS injury while providing adequate supportive care, such as oxygenation, mechanical ventilation, and intracranial pressure (ICP) monitoring. This case highlights the importance of rapid diagnosis and management of NPE in patients with acute CNS injuries. Early recognition and intervention are essential to prevent severe respiratory compromise and improve clinical outcomes. Physicians should be mindful of NPE as a potential complication in patients presenting with neurological emergencies.
Trauma is a leading cause of death worldwide, with 25% of cases involving the head and neck region. Among various trauma types, impalement injuries caused by arrows and spearguns pose significant challenges due to their potential for severe damage to critical structures. This case report aims to present a case of a speargun arrow injury to the face and to discuss the mechanisms, implications, and management of such trauma. A 44-year-old male presented with an impaled arrow in the right infraorbital area, accidentally shot by his son. Initial assessment showed a conscious patient with stable vital signs. Imaging revealed the arrow penetrating the nasomaxillary region and extending into the cervical spine. Surgical removal was performed successfully using a retrograde approach with a Foley catheter to avoid further tissue damage. This case underscores the importance of individualized treatment strategies and the critical role of imaging in managing penetrating arrow injuries. A multidisciplinary approach, rapid assessment, and careful surgical planning are essential for positive outcomes. Reporting such cases contributes to medical research and improves safety regulations and treatment protocols.
