Background: Septic arthritis is an uncommon but severe condition that can lead to rapidly progressive articular destruction and septicemia. Although the knee is the most commonly affected joint in septic arthritis, bilateral involvement is an exceedingly rare condition often associated with immunocompromising conditions, medical comorbidities or other sources of infection. Case report: A 74-year-old male immunocompetent patient presented with two to three days of atraumatic bilateral knee pain and swelling with difficulty ambulating, with presenting vital signs concerning for sepsis. Physical exam was notable for large bilateral knee effusions, warmth and significantly limited range of motion. Bilateral knee arthrocentesis was performed with synovial fluid analysis consistent with bilateral septic arthritis. The patient was managed with intravenous antibiotics and operative arthrotomy and irrigation. Synovial fluid cultures from the emergency department and operating room, as well as 4/4 blood cultures all grew Group G streptococcus. No primary source of infection was identified. The patient completed a course of intravenous antibiotics tailored to culture susceptibility and had resolution of symptoms. Why should an emergency physician be aware of this?: Polyarticular septic arthritis carries high morbidity and mortality. Although uncommon, atypical presentations and absence of usual risk factors can lead to delays or missed diagnoses in the emergency department. It is essential to maintain a high index of suspicion in the patient presenting with undifferentiated multifocal joint pain or swelling, in the appropriate clinical context, to make an early diagnosis and initiate aggressive treatment to prevent complications.
Medical emergencies. Critical care. Intensive care. First aid
Piroozeh Taheri, Mohammad Taghi Beig Mohammadi, Mostafa Mohammadi
et al.
Background: Exploring risk factors for the development of COVID-19 in vital organs of the body is necessary to improve patient survival and reduce disability and morbidity due to disease progression. By identifying these underlying risk factors and controlling them, it is possible to prevent extra-pulmonary involvement and even alleviate pulmonary involvement in patients, resulting in a significant reduction in mortality and morbidity rates. This study aimed to identify the underlying risk factors associated with pulmonary and extrapulmonary organ complications of COVID-19.
Methods: This study was a cross-sectional descriptive-analytical study. Patients with a definitive diagnosis of COVID-19 who were admitted to the intensive care unit of Imam Khomeini Hospital in Tehran due to respiratory distress and poor clinical condition were included in the study population and were clinically followed up on. Patients' information was collected by reviewing patients' records and the hospital information system.
Results: A total of 123 patients were included in the study (63.4% were male, mean age = 58.87 ± 12.37). Using ROC curve analysis, the calculated risk score is considered statistically significant for diagnostic accuracy (AUC = 0.862 [0.797–0.927], P value < value<0.001). A risk score cutoff greater than 1.5 (sensitivity 89.9%, specificity 38.9%) favors an increased likelihood of in-hospital mortality. According to multiple linear regression (F (9,93).369, P value=0.001), chronic obstructive pulmonary disease, asthma, diabetes, SOFA score on days 2 & 3, and ventilation support were predictors of ICU length of stay.
Conclusion: A history of chronic heart failure with renal impairment, liver cirrhosis with liver complication, and any underlying disease are associated with pulmonary complications in COVID-19 patients.
Anesthesiology, Medical emergencies. Critical care. Intensive care. First aid
Faezeh Aghamirzaei, Ahmad Ali Abin, Farzaneh Futuhi
Introduction: Acute Kidney Injury (AKI) is a severe complication of vancomycin treatment due to its nephrotoxic effects. However, research on predicting AKI in this high-risk group remains limited. This study presents a stacking ensemble machine learning model designed to predict the onset of AKI in this patient population.
Methods: Leveraging data from 314 ICU patients, the model incorporates SHapley Additive exPlanations (SHAP) for enhanced interpretability, identifying key predictors such as serum creatinine levels, glucose variability, and patient age. The model achieved an Area Under the Curve (AUC) of 0.94, outperforming existing predictive approaches. By utilizing readily available clinical data and determining an optimal temporal prediction window, this model facilitates proactive clinical decision-making, aiming to reduce the risk of AKI and improve patient outcomes.
Results: The stacking ensemble model achieved 92\% accuracy, 93\% precision, 92\% sensitivity, and 0.94 AUC in 314 ICU patients, pinpointing creatinine, glucose variability, and age as critical AKI predictors.
Conclusion: The findings suggest that integrating advanced machine learning techniques with interpretable artificial intelligence (AI) can provide a scalable and cost-effective solution for early AKI detection in diverse healthcare settings.
Medical emergencies. Critical care. Intensive care. First aid
Sofia-Chrysovalantou Zagalioti,1 Mairi Ziaka,2 Aristomenis Exadaktylos,2 Barbara Fyntanidou1 1Department of Emergency Medicine, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece; 2Department of Emergency Medicine, Inselspital University Hospital, University of Bern, Bern, SwitzerlandCorrespondence: Sofia-Chrysovalantou Zagalioti, Email sofia_zag@yahoo.comBackground: Accurate decision-making in triage largely determines the amount of time required for a patient to be evaluated and treated while in the emergency department. Nursing staff worldwide have similar learning characteristics with similar working hours and common goals, despite the fact that different triage scales are used globally. The aim of this mini review is to present the different educational methods and identify the most effective for triage training of triage nurses.Materials and Methods: We screened studies concerning triage education for nurses in Emergency Department, in databases including PubMed, CENTRAL and CINAHL. From November 12, 2023 to February 15, 2024, databases were searched for relevant literature. “Triage education” OR “triage training” AND “emergency nurses” OR “triage nurses” were the MeSH terms.Results: There are various educational methods, including traditional, web-based, audiovisual, simulation-based, blended learning, and other specialized approaches. Almost all of the studies that are currently available demonstrate how effectively an educational intervention might improve nurses’ comprehension of triage. Except for one, every study concluded that the educational intervention significantly improved nurses’ triage knowledge. Comparing the included studies is challenging due to their heterogeneity, and applying the results in practice requires caution.Conclusion: The majority of studies reported that educational interventions effectively increased nurses’ triage knowledge. Blended learning in conjunction with refresher courses enhanced triage-related knowledge and decision-making; however, additional research is required to ascertain whether this approach is superior to the others and whether these improvements will last.Keywords: educational method, emergency department, triage education
Medical emergencies. Critical care. Intensive care. First aid
Michael J. Domanski, MD, Colin O. Wu, PhD, Xin Tian, PhD
et al.
Background: In prior studies of cumulative risk factor exposure, self-identified race was independently associated with incident cardiovascular disease (CVD). A recent study suggests clinical, demographic, and socioeconomic factors explain racial differences. We used propensity score matching to study race as an independent incident CVD risk factor. Objectives: The purpose of this study was to assess race as an independent risk factor for incident CVD. Methods: We analyzed CARDIA (Coronary Artery Risk Development in Young Adults) study data using propensity score matching of White and Black women, and, separately, White and Black men, with respect to known CVD risk factors. Results: Black men (n = 487), compared to White men (n = 487), had higher risk of CVD (HR: 2.30; 95% CI: 1.36-3.89; P = 0.0014), stroke (HR: 5.00; 95% CI: 1.45-17.3; P = 0.0047), and congestive heart failure (CHF) (HR: 3.60; 95% CI: 1.34-9.70; P = 0.0067). Black women (n = 640), compared to White women (n = 640), had higher CVD risk (HR: 2.36; 95% CI: 1.17-4.78; P = 0.014) and stroke risk (HR: 2.80; 95% CI: 1.01-7.77; P = 0.039) and borderline significantly higher CHF risk (HR: 3.50; 95% CI: 0.73-16.9; P = 0.096). Risk of coronary heart disease did not differ significantly by race in either sex. Multivariable analyses showed racial differences in the associations of multiple risk factors with incident CVD events independent of other known CVD risk factors. Conclusions: Propensity score matching analyses demonstrate that race is an independent risk factor for incident CVD and its components, CHF, and stroke. Multivariable analyses suggest racial differences in Black vs White risk factor impact as the possible cause. Reasons for these differences remain to be explored.
Diseases of the circulatory (Cardiovascular) system, Medical emergencies. Critical care. Intensive care. First aid
Introduction: Abdominal aneurysm is considered a formidable pathological condition that requires prompt treatment. Its progressive increase leads to rupture and massive internal bleeding, which requires the most effective medical care. However, despite the improvement in medical equipment and postoperative care, mortality due to ruptured abdominal aneurysms is still close to 50%, which is primarily related to the severity of the pathology and open surgical intervention.
Materials and Methods: 46 patients diagnosed with rupture of the abdominal aorta took part in the study. Selection criteria were a history of abdominal aortic rupture, conservative/operative treatment for the disease, and absence of other complications (acute renal failure, liver infarction) that could affect the results of the study.
Results: Since January 2018, 46 cases of ruptured AAAs have been diagnosed. In all forty-six cases, surgical intervention was used: open surgery or endovascular technique. All 100% of patients had a previous history of diagnosed abdominal aortic aneurysm, for which they underwent periodic ultrasound examinations.
As a result of the study, it was found that endovascular aortic aneurysm correction is the optimal method for both planned and emergency treatment of aortic aneurysm and its rupture. According to the Cochrane Specialized Register, it was established that endovascular repair is associated with a reduction in early morbidity and mortality after abdominal aneurysm, compared with other methods of surgical treatment. Furthermore, the study found that, unlike open surgery methods, endovascular techniques are associated with a lower risk of complications in the form of intestinal ischemia.
Conclusions: Inferior quality studies and lack of information limit the conclusions of this review. From the statistical data shown in this paper, it can be concluded that there is a difference between endovascular and open methods of treatment of abdominal aortic aneurysm rupture. Mortality within the first 30 days after treatment and short-term complications are significantly lower in patients using EVAR. Systemic complications are also more prevalent in patients who were prescribed open surgical treatment.
Surgery, Medical emergencies. Critical care. Intensive care. First aid
Anna Nikula, Stefan Lundeberg, Malin Ryd Rinder
et al.
Abstract Background Procedural sedation and analgesia are commonly used in the Emergency Departments. Despite this common need, there is still a lack of options for adequate and safe analgesia and sedation in children. The objective of this study was to evaluate whether intranasal dexmedetomidine could provide more effective analgesia and sedation during a procedure than intranasal esketamine. Methods This was a double-blind equally randomized (1:1) superiority trial of 30 children aged 1–3 years presenting to the Emergency Department with a laceration or a burn and requiring procedural sedation and analgesia. Patients were randomized to receive 2.0 mcg/kg intranasal dexmedetomidine or 1.0 mg/kg intranasal esketamine. The primary outcome measure was highest pain (assessed using Face, Legs, Activity, Cry, Consolability scale (FLACC)) during the procedure. Secondary outcomes were sedation depth, parents’ satisfaction, and physician’s assessment. Comparisons were done using Mann–Whitney U test (continuous variables) and Fisher’s test (categorical variables). Results Adequate analgesia and sedation were reached in 28/30 patients. The estimated sample size was not reached due to changes in treatment of minor injuries and logistical reasons. The median (IQR) of highest FLACC was 1 (0–3) with intranasal dexmedetomidine and 5 (2–6.75) with intranasal esketamine, (p-value 0.09). 85.7% of the parents with children treated with intranasal dexmedetomidine were “very satisfied” with the procedure and sedation compared to the 46.2% of those with intranasal esketamine, (p-value 0.1). No severe adverse events were reported during this trial. Conclusions This study was underpowered and did not show any difference between intranasal dexmedetomidine and intranasal esketamine for procedural sedation and analgesia in young children. However, the results support that intranasal dexmedetomidine could provide effective analgesia and sedation during procedures in young children aged 1–3 years with minor injuries. Trial registration: Eudra-CT 2017-00057-40, April 20, 2017. https://eudract.ema.europa.eu/
Medical emergencies. Critical care. Intensive care. First aid
Bhavya Krishna, Kavita Rani Sharma, Ranju Gandhi
et al.
Pheochromocytoma is a challenging case for any anesthesiologist and a team approach is required throughout the perioperative period to prevent anticipated difficulties and best manage any unforeseen complications that develop. We discuss successful management of certain unique challenges, like multifocal arrhythmias and surgical rebleed during transport, during pheochromocytoma surgery in an adult, in addition to the usual perioperative problems.
Anesthesiology, Medical emergencies. Critical care. Intensive care. First aid
Noman Ali, Abdul Ahad Chhotani, Sannia Perwaiz Iqbal
et al.
Abstract Background Many physicians use point-of-care ultrasound (PoCUS) in their clinical practice to improve their diagnostic capabilities, accuracy, and timeliness. Over the last two decades, the use of PoCUS in the emergency room has dramatically increased. This study aimed to determine emergency physicians’ retention of knowledge and skills after a brief training workshop on a focused ultrasound-guided approach to a patient presenting with undifferentiated shock, shortness of breath, and cardiac arrest in the emergency department of a tertiary care hospital. The secondary aim was to deliver the PoCUS-guided algorithmic approach to manage a patient presenting with undifferentiated shock, respiratory distress, and cardiac arrest in the emergency department. Methods A quasi-experimental study was conducted with a single-day Point of Care Ultrasonographic Life Support in Emergency (PULSE) training workshop in October 2021 at the Aga Khan University Hospital, Karachi, Pakistan. A total of 32 participants attended the course, including twenty-one junior residents (PGY 1 and 2) and medical officers with experience of fewer than two years working in different emergency departments of urban tertiary care hospitals across Karachi, Pakistan. Pre- and post-assessment tools comprised a written examination, evaluating participants' knowledge and skills in ultrasound image acquisition and interpretation. Cronbach's alpha was used to calculate the validity of the tool. Results obtained before and after the training session were compared by the McNemar’s test. A p value of ≤ 0.05 was considered significant. Results There was a significant improvement in response to each question pre to post-test after completion of the course (Table 1). The significant change can be seen in questions 7, 8, 13, and 15, with a percentage change of 33.3, 80.9, 42.9, and 47.7. There was a significant improvement in the understanding and knowledge of participants after the training. The scores in the post-test were high compared to the pre-test in each category, i.e., respiratory distress (p < 0.017), cardiac arrest (p < 0.041), basic ultrasound knowledge (p < 0.001), and undifferentiated shock (p < 0.001). Conclusion All participants showed improvement in their knowledge and confidence regarding using PoCUS in life-threatening conditions. Through this study, we have also developed an algorithmic approach to managing undifferentiated shock, respiratory failure, and cardiac arrest. Future studies must assess the effectiveness and feasibility of incorporating these algorithms into clinical practice.
Medical emergencies. Critical care. Intensive care. First aid
Aim In acute medicine, we occasionally treat life‐threatening conditions such as sepsis and trauma, which cause severe thrombocytopenia. Serum thrombopoietin levels have been reported to increase under the condition of thrombocytopenia related to severity. Collagen is a crucial activator of platelets, and Rho family members, such as Rho/Rho‐kinase and Rac, play roles as active molecules involved in the intracellular signaling pathways in platelet activation. The present study aimed to elucidate the effects of thrombopoietin (TPO) on subthreshold low‐dose collagen‐stimulated human platelets in terms of Rho/Rho‐kinase and Rac. Methods Platelet‐rich plasma donated from healthy volunteers was stimulated by the subthreshold low‐dose of collagen after pretreatment with TPO and/or NSC23766, an inhibitor of the Rac‐guanine nucleotide exchange factor interaction, or Y27632, an inhibitor of Rho‐kinase. Platelet aggregation was measured using an aggregometer based on laser‐scattering methods. Proteins involved in intracellular signaling were analyzed using western blotting, and the secretion of platelet‐derived growth factor‐AB from activated platelets was determined using an enzyme‐linked immunosorbent assay. Results Under the existence of TPO, the low dose of collagen remarkably elicited the aggregation and platelet‐derived growth factor‐AB secretion of platelets, which were suppressed by NSC23766 and Y27632. The combination of TPO and collagen considerably induced a transient increase of guanosine triphosphate (GTP)‐binding Rac and GTP‐binding Rho followed by an increase of phosphorylated cofilin, a Rho‐kinase substrate. Conclusion These results strongly suggest that TPO and collagen in low doses cooperatively potentiate human platelet activation through both Rac and Rho/Rho‐kinase mediated pathways.
Medical emergencies. Critical care. Intensive care. First aid
Akiko Tomita-Kobayashi, Tomoko Fujimoto, Shoko Takada
et al.
Abstract Background Symptomatic sick sinus syndrome is one of the indications for pacemaker implantation, and we have to consider to program the pacemaker to an asynchronous pacing mode during an operation. Case presentation We reported two cases with a pacemaker implanted for sick sinus syndrome undergoing cardiac operation. We changed programming of the pacemaker to an asynchronous pacing mode (DOO) and modulated the programmed atrioventricular delay to avoid ventricular pacing, resulting in better hemodynamic condition. Although we observed premature ventricular contraction, no lethal arrhythmias induced by the R-on-T phenomenon were noted. Conclusion Programming of the pacemaker to an asynchronous pacing mode and modulation of the programmed atrioventricular delay to avoid ventricular pacing may be an option for pacemaker management during an operation.
Anesthesiology, Medical emergencies. Critical care. Intensive care. First aid
Heather Prendergast, Carissa Tyo, Christopher Colbert
et al.
Abstract Background Obesity is a major public health problem associated with significant medical complications. Main body This review examines 8 primary diseases: type 2 diabetes, hypertension, dementia, non-alcoholic fatty liver disease, polycystic ovarian syndrome, dyslipidemia, cancer, and their manifestations in obese patients. A total of 39 articles were used for this review. The authors conducted limited review, searching PubMed and Google Scholar databases using a combination of key words “COVID-19” or “SARS-COV2”, “type 2 diabetes”, “hypertension”, “dementia”, “non-alcoholic fatty liver disease”, “polycystic ovarian syndrome”, “dyslipidemia”, “cancer”, and “obesity”. No specific date limitation was used. Obesity exacerbates many medical conditions and has recently been identified as an independent risk factor for COVID-19 severity. This sets obesity at the pinnacle of all disease complications. The long-term impact of obesity ranges from financial burden on the health system, lower life expectancy, and reduced survival rates. Conclusion Obesity is an important modifiable risk factor. There is the need for healthcare providers to understand the medical complications associated with obesity to optimize patient care.
Medical emergencies. Critical care. Intensive care. First aid
Shegaw Zeleke,1 Demewoz Kefale2 1Department of Adult Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia; 2Department of Pediatric and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, EthiopiaCorrespondence: Shegaw Zeleke Email shegawzn@gmail.comBackground: Oxygen therapy is a medical treatment and prescribed to prevent or treat hypoxemia. Based on a WHO report every year at least 1.4 million deaths occur due to the lack of supplemental oxygen therapy and inappropriate administration of oxygen.Objective: To assess the knowledge and practice of nurses on supplemental oxygen therapy in Debre Tabor General Hospital, 2019.Methods: Data was collected using structured questionnaires that measure nurses’ knowledge and practice regarding supplemental oxygen therapy. Data were entered using Epi Data version 3.1 and analyzed using SPSS version 23. Bivariate and multivariate analyses were conducted to examine the association between independent and outcome variables.Results: Only one-third of nurses had a good practice on supplemental oxygen administration. Nurses who had good knowledge of supplemental oxygen administration were 12-times (AOR=12.25, 95% CI=6.48– 32.93) more likely to have a good practice of supplemental oxygen administration than those who had poor knowledge of supplemental oxygen administration.Conclusion: There is a clear knowledge and practice gap among nurses working in Debre Tabor General Hospital. The knowledge and practice level of nurses in the study area is low compared with others. The possible factors were identified; such as lack of supplemental oxygen therapy training, absence of supplemental oxygen administration standard guidelines, workload, and inadequate supply of oxygen and delivery devices.Keywords: knowledge, practice, supplemental oxygen therapy, nurse
Medical emergencies. Critical care. Intensive care. First aid
The review summarizes data on contemporary approaches to diagnosis, prevention and treatment of severe acute parenchymal respiratory failure of various origins including in acute respiratory distress syndrome (ARDS) caused by bacterial and viral pneumonia. It is based on the data of modern properly organized studies, an analysis of international clinical guidelines with a high degree of evidence, as well as the results of many years of own experimental research and clinical observations of treatment of patients with ARDS of various origin, including those with viral pneumonia in 2009–2016–2020. The article states scientifically-based procedures for prevention, differential diagnosis and personalized treatment of severe acute respiratory failure with the use of innovative medical technologies and a wide range of respiratory treatments. The authors did their best to adapt specific proposals for everyday clinical practice.
Medical emergencies. Critical care. Intensive care. First aid