In 2009, the World Health Organization included snakebite on the list of neglected tropical diseases, acknowledging it as a common occupational hazard for farmers, plantation workers, and others, causing tens of thousands of deaths and chronic physical disabilities every year. This guideline aims to provide practical information to help clinical professionals evaluate and treat snakebite victims. These recommendations are based on clinical experience and clinical research evidence. This guideline focuses on the following topics: snake venom, clinical manifestations, auxiliary examination, diagnosis, treatments, and prevention.

目的 分析血清和肽素(copeptin)联合N末端脑钠肽前体(NT-proBNP)对急危重症患者30d死亡的预测价值.方法 选择北京医院急诊科 2017 年 3 月至 2019 年 2 月入住急诊抢救室或重症监护室的患者 201 例作为研究对象,来诊时立即留取血清标本测定和肽素、NT-proBNP水平及其他常用临床血液指标,所有病例均随访30 d,记录患者生存情况.临床资料采用SPSS 25.0 软件进行统计处理.结果 血清和肽素水平在 30d随访死亡组与生存组之间差异有统计学意义(32.350 pg/mL vs.12.378 pg/mL).经独立危险因素Logistic 二元回归模型分析,血清和肽素、ln(NT-proBNP)对急危重症患者的预后有独立预测意义(OR值分别为1.069、1.768).ROC曲线分析提示,和肽素、NT-proBNP的AUC分别为 0.762、0.703,二者联合预测ROC曲线AUC为0.840,优于单一指标AUC.进一步分析发现,两者均呈高水平的患者较之低水平患者病死率明显增高.结论 血清和肽素及NT-proBNP均可作为急危重症患者30d死亡风险的独立预测因子,对急危重症患者的预后有较好的辅助预测价值,且两指标联合相较于单一指标预测预后价值更大.

Chromium-doped multiferroic bismuth ferrite BiFe1-xCrxO3 (x = 0.0, 0.05, 0.10, 0.15, 0.20) nanoparticles were synthesized by the conventional hydrothermal method. The effects of Cr doping on the structural and magnetic properties of BiFeO3 nanoparticles were investigated at room temperature using X-ray diffraction (XRD), X-ray absorption fine structure (XAFS) spectroscopy and superconducting quantum interference device (SQUID). From the scanning electron microscope (SEM) images, the morphology of BiFeO3 nanoparticles was effected obviously by Cr doping, though the actual doping concentrations were below 4% according to the inductively coupled plasma mass spectrometry (ICP-MS) results. The XRD results showed that all samples had rhombohedral R3c crystal structure without any impurity phase, and further confirmed by the Bi L3-edge and Fe K-edge XAFS spectra. However, the Cr K-edge XAFS results of the doped samples revealed the presence of the oxides related Cr as the doping concentration increase. Furthermore, different Cr-doped concentrations played an important role on the magnetic enhancement of BiFeO3, and the abnormal performance of magnetism might be attributed to the unexpected oxides.

Objective:To investigate the prognostic value of copeptin(COP)and troponin I(cTnI)for elderly patients with acute myocardial infarction(AMI).Methods:81 elderly AMI patients admitted to the Department of Emergency of Beijing Hospital from August 2016 to August 2018 were included as study subjects.COP and cTnI were measured and other relevant examinations were conducted.The correlation between each factor and the risk of death was evaluated in a 6-month follow-up, and the prognostic value of each indicator was assessed.Results:There were statistically significant differences in COP, cTnI, arterial lactic acid(LAC), the acute physiology and chronic health evaluation(APACHE)Ⅱ score, D-Dimer and N-terminal brain natriuretic peptide precursor(NT-pro-BNP)between the survival group and the death group(all P<0.05).COP and cTnI levels in the death group were significantly higher than those in the survival group[COP: 29.08(13.73, 43.19)ng/L vs.13.76(4.81, 20.82)ng/L; cTnI: 0.78(0.35, 2.23)μg/L vs.0.33(0.19, 0.57)μg/L].Binary Logistic regression analysis showed that COP( OR=1.071, 95% CI: 1.016-1.130, P=0.040)and cTnI( OR=3.261, 95% CI: 1.058-10.045, P=0.011)were independent risk factors for death within 6 months in elderly AMI patients.The ROC curves were constructed for cTnI, COP and their combination, and the AUCs(95% CI)were 0.742(0.593-0.892), 0.752(0.655-0.910)and 0.790(0.648-0.932), respectively. Conclusions:COP and cTnI may be used to assess the prognosis for elderly patients with AMI, and their combination can further increase the predictive value for short-term death risk.

目的 探讨心肌肌钙蛋白I(cTnI)、N末端B型利钠肽原(NT-proBNP)联合国家早期预警评分(NEWS)对心血管急重症患者近期预后的评估作用.方法 连续入选2013年9月至2015年7月北京医院急诊科抢救室收治的222例心血管急重症患者.记录患者的一般情况、入抢时生命体征和意识状态,对其进行NEWS评分;并检测静脉血cTnI、NT-proBNP水平;随访30 d,根据预后分为存活组和死亡组.通过多因素回归分析、绘制受试者工作特征(ROC)曲线、计算ROC曲线下面积(AUC值)评价cTnI、NT-proBNP、NEWS评分及联合检测对患者预后的评估价值.结果 心血管急重症患者死亡组与存活组的cTnI、NT-proBNP和NEWS评分比较,差异均有统计学意义(均为P<0.05).多因素回归分析显示,cTnI、NT-proBNP和NEWS评分均为30 d死亡风险的独立预测因子(均为P<0.05),其AUC值分别为0.669、0.724和0.706,三者之间比较无统计学差异(P>0.05);三者的临界值分别为0.03 ng/ml、3197 pg/ml和7分,高于临界值水平,患者30 d死亡率较高;高于临界值项目越多,患者30 d死亡率越高.cTnI、NT-proBNP联合NEWS评分的AUC值明显高于单独应用NEWS评分的AUC值(0.764、0.786比0.706,均为P<0.05);三者联合的AUC值最大,为0.809,明显高于三者单独应用的AUC值(均为P<0.05).结论 cTnI、NT-proBNP、NEWS评分均为心血管急重症患者30 d不良预后的独立预测因子.cTnI、NT-proBNP联合NEWS评分可明显提高评估患者不良预后的价值,而三者皆升高对30 d不良预后的评估意义最大.

心力衰竭( heart failure, HF,简称心衰)是大部分心血管疾病发展的最终阶段,其发病率高,目前我国≥35岁人群心衰的患病率为1 . 3％,估计有心衰患者890万."老龄化"是心衰发病率增加的主要原因之一,65岁以后,年龄每增加10 岁,心衰的发病率增加2倍(男性)和3 倍(女性).急性心力衰竭(acute heart failure, AHF)是指继发于心脏功能异常而迅速发生或恶化的症状和体征,并伴有血浆利钠肽水平的升高,临床上表现为新发的AHF (左心或右心衰竭)以及急性失代偿心力衰竭( acute decompensated heart failure, ADHF) ,其中ADHF多见,约占70％.

Chinese emergency department (ED) staff encountered significant mental stress while fighting the coronavirus disease 2019 (COVID-19) pandemic. We sought to investigate the prevalence and associated factors for depressive symptoms among ED staff (including physicians, nurses, allied health, and auxiliary ED staff). A cross-sectional national survey of ED staff who were on duty and participated in combating the COVID-19 pandemic was conducted March 1–15, 2020. A total of 6,588 emergency medical personnel from 1,060 hospitals responded to this survey. A majority of respondents scored above 10 points on the PHQ-9 standardized test, which is associated with depressive symptoms. Those aged 31–45, those working in the COVID-19 isolation unit, and those with relatives ≤ 16 or ≥70 years old at home all had statistically significant associations with scoring >10 points. Depressive symptoms among Chinese emergency medical staff were likely quite common during the response to the COVID-19 pandemic and reinforce the importance of targeted ED staff support during future outbreaks.

心脏骤停是目前公共卫生面临的重大课题与挑战,也是急诊科时常要面对的最紧急状况.美国每年有30～60万人因心脏骤停而死亡,我国近年来的发生人数也呈逐年上升趋势.80％以上的心脏骤停由恶性室性心律失常引发,心室颤动是其中最严重类型,也是其他室性心律失常发展的趋势和结果,可直接危及患者生命.电除颤是终止心室颤动最有效的方法[1].电除颤是指在严重快速型室性心律失常时,用额定短暂高能脉冲电流通过心脏,使全部或大部分心肌细胞在瞬间同时除极,造成心脏短暂的电活动停止,然后由最高自律性起搏点(通常为窦房结)重新主导心脏节律的治疗过程.电除颤是心脏电复律技术的一种,又称非同步心脏电复律.

目的 了解北京医院急诊科2017～2019年临床分离碳青霉烯类耐药肺炎克雷伯菌(CRKP)分布特点、变化趋势及危险因素.方法 收集北京医院急诊科2017年1月至2019年12月从临床送检标本中分离的肺炎克雷伯菌,分析其耐药特点及分布.回顾性分析肺炎克雷伯菌感染患者的临床资料,根据是否存在碳青霉烯类耐药将患者分为CRKP组(n=87)和碳青霉烯类敏感肺炎克雷伯菌(CSKP)组(n=65).采用二元Logistic回归分析CRKP感染的危险因素.药敏试验采用纸片扩散法(Kirby-Bauer法).分别按美国临床实验室标准化协会(CLSI)2017年版、2018年版和2019年版对各年药敏试验结果进行判断,采用WHONET 5.6版本和SPSS 25.0软件统计分析数据.结果 2017～2019年急诊科送检的病原学标本中分离出肺炎克雷伯菌分别为59株(27.7％)、57株(27.9％)、50株(25.0％),在每年分离出的革兰阴性杆菌中始终排在首位.产超广谱β-内酰胺酶(ESBLs)肺炎克雷伯菌所占比例稳定在70％左右;CRKP所占比例近三年有下降趋势;基础有呼吸系统疾病、留置中心静脉导管、入住ICU≥5 d及三个月内使用碳青霉烯类药物是CRKP感染的危险因素.结论 我院急诊科肺炎克雷伯菌耐药问题严峻,尤其是碳青霉烯类耐药肺炎克雷伯菌检出率高,给临床治疗带来挑战,应加强防控.

A 66-year-old woman with a history of hyperlipidemia presented to the emergency department after a epileptic seizure episode for nearly 1 min. She had a normal temperature, pulse rate was 77 beats/min, blood pressure was 85/40 mm Hg, and pulse oximetry was 92% on room air.She felt chest tightness when exercise for 1 week. Laboratory test was significant for cardiac troponin I level of 0.12 ng/ml, B-type natriuretic peptide lever of 866.96 pg/ml, D-dimer lever of 2520 ng/ml. She had a head computerized tomography of no cerebral hemorrhage or infarction. The emergency physician prescribed sodium valproate to Control the seizures. And the physician performed point-of-care ultrasonography (Fig. 1 and Video 1). Diagnosis was confirmed with computer tomography pulmonary angiography (CTPA, Fig. 2).Fig. 2CTPA showing filling-defect of bilateral pulmonary artery Trunk (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Acute Pulmonary embolism. CTPA scan demonstrated Extensive pulmonary embolism in both pulmonary artery trunk. Intravenous Alteplase rt-PA were administered. After 10 days hospitalization, she was discharged from hospital with Rivaroxaban.6 months after discharge date, the follow-up CT scan showed no pulmonary embolism (Fig. 3). It is rare that seizure is the first clinical manifestation of acute pulmonary embolism [[1]Zuin M. Rigatelli G. Zuliani G. et al.Seizures as the first clinical manifestation of acute pulmonary embolism: an underestimate issue in neurocritical care.Neurol Sci. 2020; 41: 1427-1436Crossref PubMed Scopus (2) Google Scholar,[2]WANG Jian-wen XU Ming-wei LUO Ben-yan Pulmonary embolism presenting as recurrent transient loss of consciousness: syncope and seizure.Chin Med J. 2013; 126: 193-194PubMed Google Scholar]. point-of-care ultrasonography is a useful tool for physicians to diagnose rapidly whether acute Pulmonary embolism exists or not [[3]Squizzato A. Galli L. Gerdes V.E. Point-of-care ultrasound in the diagnosis of pulmonary embolism.Crit Ultrasound J. 2015; 7: 7-10Crossref PubMed Scopus (22) Google Scholar], especially for unstable patients. This work was supported by Peking Union Medical Foundation–Ruiyi Emergency Medical Research Fund (R2018028).

Introduction: Long-term use of antibiotics for septic patients leads to bacterial resistance, increased mortality, and hospital stay. In this study, we investigated an emerging biomarker presepsin-guided strategy, which can be used to evaluate the shortening of antibiotic treatment in patients with sepsis without risking a worse outcome. Methods: In this multicenter prospective cohort trial, patients were assigned to the presepsin or control groups. In the presepsin group, antibiotics were ceased based on predefined cut-off ranges of presepsin concentrations. The control group stopped antibiotics according to international guidelines. The primary endpoints were the number of days without antibiotics within 28 days and mortality at 28 and 90 days. Secondary endpoints were the percentage of patients with a recurrent infection, length of stay in ICU and hospital, hospitalization costs, days of first episode of antibiotic treatment, percentage of antibiotic administration and multidrug-resistant bacteria, and SOFA score. Results: Overall, 656 out of an initial 708 patients were eligible and assigned to the presepsin group (n = 327) or the control group (n = 329). Patients in the presepsin group had significantly more days without antibiotics than those in the control group (14.54 days [SD 9.01] vs. 11.01 days [SD 7.73]; P< 0.001). Mortality in the presepsin group showed no difference to that in the control group at days 28 (17.7% vs. 18.2%; P = 0.868) and 90 (19.9% vs. 19.5%; P = 0.891). Patients in the presepsin group had a significantly shorter mean length of stay in the hospital and lower hospitalization costs than control subjects. There were no differences in the rate of recurrent infection and multidrug-resistant bacteria and the SOFA score tendency between the two groups. Conclusions: Presepsin guidance has potential to shorten the duration of antibiotic treatment in patients with sepsis without risking worse outcomes of death, recurrent infection, and aggravation of organ failure.

Purpose Copeptin, reflecting vasopressin release, as well as the National Early Warning Score (NEWS), reflecting the severity of critical illness, might qualify for survival prediction in elderly patients with acute and critical illness. This prospective observational study aimed at assessing the predictive value of copeptin combined with NEWS on the prognosis of elderly patients with acute and critical illness. Methods We analyzed serum copeptin levels and the NEWS at admission to the emergency department (ED) in a prospective, single-center and observational study comprising 205 elderly patients with acute and critical illness. Death within 30 days after admission to the ED was the primary end point. Results The serum copeptin levels and the NEWS in the non-survivor patients group were higher than those in the survivor group [30.35 (14.20, 38.91) vs 17.53 (13.01, 25.20), P = 0.001 and 9.0 (7.0–10.0) vs 7.0 (6.0–8.0), P = 0.001]. Multivariate logistic regression analysis showed that Copeptin, NEWS and copeptin combined with NEWS were all independent risk factors for 30-day mortality in elderly patients with acute and critical illness. Copeptin, NEWS and copeptin combined with NEWS all performed well in predicting 30-day survival, with area under the ROC curve (AUC) values of 0.766 (95%CI, 0.702–0.822), 0.797 (95%CI, 0.744–0.877) and 0.854 (95%CI, 0.798–0.899) respectively. Using the Z test to compare the areas under the above three curves, copeptin combined with NEWS showed a higher predictive value for 30-day survival (P < 0.05). As we calculated, the optimal cut-off value of copeptin and NEWS using the Youden index were 19.78 pg/ml and 8.5 points respectively. Risk stratification analysis showed that patients with both higher copeptin levels and higher NEWS had the highest risk of death. Conclusions Copeptin combined with NEWS have a stronger predictive power on the prognosis of elderly patients with acute and critical illness, comparing to either factor individually.

Background: Long-term use of antibiotics for septic patients leads to antibiotic resistance. This study aimed at assessing the benefit and safety of an emerging biomarker presepsin on guiding antibiotic courses for patients with sepsis. Methods: In this multicenter prospective cohort trial, patients were assigned to the presepsin or control groups. In the presepsin group, antibiotics were ceased based on predefined cut-off ranges of presepsin concentrations. The control group stopped antibiotics according to international guidelines. The primary endpoints were the number of days without antibiotics within 28 days (superiority analysis) and mortality at 28 and 90 days (non-inferiority analysis). The margin of non-inferiority was 10%. Results: Overall, 656 out of an initial 708 patients were eligible and assigned to the presepsin group (n=327) or the control group (n=329). Patients in the presepsin group had significantly more days without antibiotics than those in the control group (14.54 days [SD 9.01] vs 11.01 days [SD 7.73]; absolute difference 3.64 days, p =0.000). Mortality in the presepsin group was non-inferior to that in the control group at days 28 (17.7% vs 18.2%; absolute difference -0∙5%, 90% CI -5.4 to 4.4) and 90 (19.9% vs 19.5%; 0.4%, -4.7 to 5.5). Patients in the presepsin group had a significantly shorter mean length of stay in the hospital and lower hospitalization costs than control subjects. Conclusions: Presepsin guidance reduces the duration of antibiotic treatment in patients with sepsis without increasing mortality. Trial registration: ChiCTR, ChiCTR1900024391. Registered 9 July 2019. Retrospectively registered.

目的 探讨老年急危重症患者重新摄入营养时并发再喂养综合征(refeedingsyndrome,RFS)对近期预后的影响及风险因素.方法 回顾性分析我院急诊科2019年1月1日至2020年6月30日有营养不良风险的老年急危重症患者共145例,根据RFS诊断标准,诊断RFS或亚临床RFS 65例为研究组,其余80例为对照组,对比两组患者性别、年龄、BMI指数、纳差时间、营养方式、每日摄入热卡值、糖脂供能等情况,并分析患者出现低磷血症或RFS与预后的关系.结果 两组性别、BMI、纳差时间差异无统计学意义(P>0.05).研究组患者年龄高于对照组(岁:80.91±9.46 vs.77.57±10.07,P=0.044).在诊治过程中出现RFS患者病死率高于未出现RFS患者(52.3％vs.15.0％,χ2=23.045,P=0.000).ROC曲线分析发现,72 h血磷下降值曲线下面积为0.811,95％CI为(0.734,0.888).72 h血磷下降值的约登指数最大截断值为0.395mmol/L.在营养支持治疗过程中研究组入院RFS危险因素分层、初始进行的营养类型、碳水化合物供能比例与对照组差异无统计学意义(P>0.05).初始热卡摄入5～10 kcal/(kg·d)组出现RFS比例低于<5 kcal/(kg·d)组及≥10 kcal/(kg·d)组(χ2=7.779,P=0.020).结论 诊治过程中出现RFS是影响老年急危重症患者近期不良预后的重要因素,有营养不良风险的老年急危重症患者中,RFS可能与初始热卡摄入情况有关.

Objective:To investigate the relationship of etiology and complications of rhabdomyolysis with its prognosis in the elderly.Methods:Patients with rhabdomyolysis at the emergency department of our hospital from January 1, 2018 to December 31, 2019 were retrospectively analyzed.Based on age, patients were divided into the non-elderly group(<65 years old)and the elderly group(≥65 years old). The frequency distribution of etiological factors, concurrent acute kidney injury, and their association with prognosis were analyzed.Results:The number of patients with rhabdomyolysis caused by 2 or more etiologies was higher in the elderly group than in the non-elderly group(40.3% or 48/119 vs.17.0% or 16/94, χ2=13.582, P=0.000). The frequency distribution of etiological factors was different between the two groups.The top-five etiologies were infection, muscle ischemia/hypoxia, endocrine metabolic abnormalities, trauma and muscle fatigue in the elderly group and muscle fatigue, infection, endocrine metabolic abnormalities, drugs/toxicants and trauma in the non-elderly group.Compared with the non-elderly group, the elderly group had fewer patients with typical clinical manifestations(32.8% or 39/119 vs.48.9% or 46/94, χ2=5.067, P=0.024). In contrast, patients who newly presented with disturbance of consciousness were more likely to be found in the elderly group than in the non-elderly group(40.3% or 48/119 vs.21.3% or 20/94)( χ2=7.923, P=0.005). There were 37 patients with AKI(38.9% or 37/95)in the elderly group and 13 of them died(35.1%), and there were 17 patients with AKI in the non-elderly group(19.3% or 17/88)and 4 died(23.5%), indicating the elderly were prone to AKI( χ2=7.545, P=0.006). There was a significant correlation between AKI and prognosis in the non-elderly group( χ2=7.196, P=0.007). Conclusions:Rhabdomyolysis caused by multiple etiologies is more common in elderly patients than in non-elderly patients.The etiological classification of rhabdomyolysis in the elderly is different from that in the non-elderly.Elderly patients are less likely to have typical clinical manifestations and are more prone to AKI.Elderly patients with rhabdomyolysis combined with AKI have a poor prognosis.

心房颤动( atrial fibrillation, AF,简称房颤)发病率随年龄增长而增加,是老年人群中发病率最高的一类心律失常.上世纪八十年代的文献报道显示,40岁以上AF发病率每年增加0 . 1％ ～0 . 2％, 60岁以上人群发病率为2％ ～4％[1-2];近期意大利的一个研究报道了年龄≥65岁老年人群无已知AF也未应用抗凝治疗的AF发生率总体为5 . 5％,其中65～74岁为3. 6％,≥75岁为7. 5％[3].AF发生率之所以高是有其解剖与生理学基础的:其一,窦房结起源的激动在向心房左下方纵行传导扩散时,不同部位心房肌除极与复极的同步性差;其二,心房肌的动作电位时间较心室肌短,使心房肌有效不应期明显缩短,这是心房接受快频率激动的必要条件;其三,随着老化,左室僵硬度增加,左房增大(从20岁到80岁,经体型校正后,左房容量增大约50％) ,心房扩大或心房传导延缓,易致折返,各种心脏病理情况下更是如此.

Objective:To investigate the clinical diagnostic value of soluble leukocyte differentiation antigen 14 subtype (sCD14-ST, presepsin) in elderly patients with acute left heart failure (AHF) complicated with bacterial pneumonia.Methods:The data of 111 elderly patients with acute left heart failure complicated with bacterial pneumonia or acute left heart failure (the control group) who were admitted into emergency department from August 2017 to August 2018 were retrospectively analyzed. Chemilluminescence immunoassay was performed to detect presepsin in all patients. And meanwhile, fever or not, presepsin, procalcitonin (PCT), C-reaction protein (CRP) and other clinical data were compared between the two groups. Univariate and multivariate logistic regression analysis were adopted to screen the risk factor influencing the diagnosis. The receiver operating characteristic (ROC) curve was used to analyze the clinical value of presepsin on diagnosing acute left heart failure complicated with bacterial pneumonia in elderly patients.Results:Presepsin of the group complicated with bacterial pneumonia was significantly higher than that of the control group [(500.9±283.5) ng/L vs. (167.7±102.3) ng/L, t=-7.902, P=0.000]. The logistic regression analysis, showed that fever, presepsin and procalcitonin were independent risk factors for AHF combined with bacterial pneumonia diagnosis. The area under ROC curve (AUC) of presepsin, PCT and WBC was 0.887 (95% CI: 0.825-0.949, P<0.001), 0.794(95% CI: 0.704-0.885, P<0.001), and 0.566 (95% CI: 0.455-0.678, P=0.231), respectively. The optimal threshold value of presepsin was 227 ng/L, the sensitivity was 82.0%, specificity was 83.6%, the positive likelihood ratio was 5, the negative likelihood ratio was 0.22, the positive predictive value) was 80.4%, and the negative predictive value was 85%. Conclusions:Presepsin has an important diagnostic value for the identification of AHF combined with bacterial pneumonia in elderly patients.