RESUMEN
BACKGROUND: Cervical spinal cord injury (CSCI) is devastating with ventilator-associated pneumonia being a main driver of morbidity and mortality. Laparoscopic diaphragm pacing implantation (DPS) has been used for earlier liberation from mechanical ventilation. We hypothesized that DPS would improve respiratory mechanics and facilitate liberation. METHODS: We performed a retrospective review of acute CSCI patients between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity score matching based on age, Injury Severity Score, ventilator days, hospital length of stay, and need for tracheostomy. Patients with complete respiratory mechanics data were analyzed and compared. Those who did not have DPS (NO DPS) had spontaneous tidal volume (Vt) recorded at time of intensive care unit admission, at day 7, and at day 14, and patients who had DPS had spontaneous Vt recorded before and after DPS. Time to ventilator liberation and changes in size of spontaneous Vt for patients while on the ventilator were analyzed. Bivariate and multivariate logistic and linear regression statistics were performed using STATA v10. RESULTS: Between July 2011 and May 2017, 37 patients that had DPS were matched to 34 who did not (NO DPS). Following DPS, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs. -13 mL; 95% confidence interval, 46-131 mL vs. -78 to 51 mL, respectively; p = 0.004). Median time to liberation after DPS was significantly shorter (10 days vs. 29 days; 95% CI, 6.5-13.6 days vs. 23.1-35.3 days; p < 0.001). Liberation prior to hospital discharge was not different between the two groups. The DPS placement was found to be associated with a statistically significant decrease in days to liberation and an increase in spontaneous Vt in multivariate linear regression models. CONCLUSION: The DPS implantation in acute CSCI patients produces significant improvements in spontaneous Vt and reduces time to liberation from mechanical ventilation. Prospective comparative studies are needed to define the clinical benefits and potential cost savings of DPS implantation. LEVEL OF EVIDENCE: Therapeutic IV.
Asunto(s)
Diafragma , Terapia por Estimulación Eléctrica , Neumonía Asociada al Ventilador/prevención & control , Insuficiencia Respiratoria/terapia , Traumatismos de la Médula Espinal/complicaciones , Enfermedad Aguda , Adulto , Vértebras Cervicales , Electrodos Implantados , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Unidades de Cuidados Intensivos , Tiempo de Internación , Modelos Lineales , Modelos Logísticos , Masculino , Persona de Mediana Edad , Neumonía Asociada al Ventilador/etiología , Respiración , Respiración Artificial/efectos adversos , Insuficiencia Respiratoria/etiología , Mecánica Respiratoria , Estudios Retrospectivos , Adulto JovenRESUMEN
BACKGROUND: A brief review of the historical aspects of esophageal rupture is presented along with a case and current recommendations for diagnostic evaluation and treatment. CASE REPORT: A 97-year-old woman complained of acute dyspnea without prior vomiting. Chest x-ray study showed a large right pneumothorax with associated effusion. A thoracostomy tube was placed with return of > 1 L turbid fluid with polymicrobial culture and elevated pleural fluid amylase level. Chest computed tomography (CT) scan demonstrated overt leakage of oral contrast into the right pleural space. She was treated with ongoing pleural evacuation, antibiotics, antifungals, and total parenteral nutrition. The patient and family declined surgical resection as well as endoscopic stent placement. In 1724, Boerhaave described spontaneous rupture of the esophagus postmortem; Boerhaave syndrome remains the name for complete disruption of the esophageal wall in the absence of pre-existing pathology typically occurring after vomiting. It most commonly occurs in the distal left posterolateral thoracic esophagus. Contrast esophagram is considered the "gold standard" for diagnosing esophageal rupture although CT esophagography also shows good diagnostic performance. Treatment includes nil per os status, broad-spectrum antibiotics, and drainage of the pleural space. Surgical repair of the esophageal perforation should be done early if the patient is deemed a good candidate, and esophageal stenting is also an option. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Esophageal perforation should be suspected in patients with new pleural effusion, often with overt pneumothorax, that is polymicrobial with elevated amylase.
Asunto(s)
Perforación del Esófago/complicaciones , Perforación del Esófago/diagnóstico , Hidroneumotórax/etiología , Enfermedades del Mediastino/complicaciones , Enfermedades del Mediastino/diagnóstico , Rotura Espontánea/complicaciones , Anciano de 80 o más Años , Disnea/etiología , Perforación del Esófago/historia , Esófago/lesiones , Esófago/fisiopatología , Femenino , Historia del Siglo XVIII , Humanos , Hidroneumotórax/fisiopatología , Enfermedades del Mediastino/historia , Derrame Pleural , Tomografía Computarizada por Rayos X/métodosAsunto(s)
Angioedema/diagnóstico , Úvula , Adulto , Servicio de Urgencia en Hospital , Humanos , MasculinoAsunto(s)
Embolia Pulmonar/complicaciones , Accidente Cerebrovascular/complicaciones , Trombosis de la Vena/complicaciones , Anciano de 80 o más Años , Angiografía Cerebral , Femenino , Heparina/uso terapéutico , Humanos , Imagen por Resonancia Magnética , Tomógrafos Computarizados por Rayos X , Trombosis de la Vena/etiología , Trombosis de la Vena/prevención & controlRESUMEN
BACKGROUND: Adult respiratory distress syndrome is often refractory to treatment and develops after entering the health care system. This suggests an opportunity to prevent this syndrome before it develops. The objective of this study was to demonstrate that early application of airway pressure release ventilation in high-risk trauma patients reduces hospital mortality as compared with similarly injured patients on conventional ventilation. METHODS: Systematic review of observational data in patients who received conventional ventilation in other trauma centers were compared with patients treated with early airway pressure release ventilation in our trauma center. Relevant studies were identified in a PubMed and MEDLINE search from 1995 to 2012 and included prospective and retrospective observational and cohort studies enrolling 100 or more adult trauma patients with reported adult respiratory distress syndrome incidence and mortality data. RESULTS: Early airway pressure release ventilation as compared with the other trauma centers represented lower mean adult respiratory distress syndrome incidence (14.0% vs. 1.3%) and in-hospital mortality (14.1% vs. 3.9%). CONCLUSION: These data suggest that early airway pressure release ventilation may prevent progression of acute lung injury in high-risk trauma patients, reducing trauma-related adult respiratory distress syndrome mortality. LEVEL OF EVIDENCE: Systematic review, level IV.
Asunto(s)
Presión de las Vías Aéreas Positiva Contínua , Síndrome de Dificultad Respiratoria/prevención & control , Heridas y Lesiones/terapia , Adulto , Presión de las Vías Aéreas Positiva Contínua/mortalidad , Mortalidad Hospitalaria , Humanos , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/mortalidad , Factores de Riesgo , Heridas y Lesiones/mortalidadAsunto(s)
Enfermedades del Colon/diagnóstico por imagen , Hernia/diagnóstico por imagen , Región Lumbosacra/lesiones , Heridas no Penetrantes/complicaciones , Accidentes de Tránsito , Adulto , Enfermedades del Colon/etiología , Hernia/etiología , Humanos , Masculino , Músculo Esquelético/lesiones , Traumatismos de los Tejidos Blandos/complicaciones , Fracturas de la Columna Vertebral/diagnóstico por imagen , Tomografía Computarizada por Rayos XAsunto(s)
Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/rehabilitación , Articulación Esternoclavicular/lesiones , Adolescente , Traumatismos en Atletas , Estudios de Seguimiento , Humanos , Masculino , Aparatos Ortopédicos , Recuperación de la Función , Articulación Esternoclavicular/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoAsunto(s)
Hemorragia Cerebral/etiología , Leucocitosis/complicaciones , Leucocitosis/patología , Adulto , Muerte Encefálica , Hemorragia Cerebral/diagnóstico por imagen , Resultado Fatal , Humanos , Recuento de Leucocitos , Masculino , Leucemia-Linfoma Linfoblástico de Células Precursoras/complicaciones , Leucemia-Linfoma Linfoblástico de Células Precursoras/patología , RadiografíaAsunto(s)
Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Ácido Ascórbico , Colecalciferol , Deshidroepiandrosterona/análogos & derivados , Humanos , Tiempo de Internación/estadística & datos numéricos , Ácidos Nicotínicos , Extractos VegetalesRESUMEN
BACKGROUND: Epidemiologic studies of stroke in the 1970s and 1980s have reported the percentage of ischemic stroke as 73% to 86%, with hemorrhagic stroke as only 8% to 18%; the remainder was undetermined (due to not performing computed tomographic [CT] scanning or an autopsy). In our clinical work, it appeared anecdotally to the authors that we were seeing more hemorrhagic strokes than these previously quoted figures. METHODS: We conducted a retrospective review for 1 year of all patients discharged from the hospital, a regional stroke center, with a diagnosis of stroke; we compared ischemic to hemorrhagic stroke types. RESULTS: There were 757 patients included. Of the patients, 41.9% were hemorrhagic and 58.1% were ischemic. CONCLUSION: There were a much greater percentage of hemorrhagic strokes in this population than would have been predicted from previous studies. This finding may be due to improvement of CT scan availability and implementation unmasking a previous underestimation of the actual percentage or to an increase in therapeutic use of antiplatelet agents and warfarin causing an increase in the incidence of hemorrhage.
Asunto(s)
Isquemia Encefálica/epidemiología , Hemorragias Intracraneales/epidemiología , Sistema de Registros , Accidente Cerebrovascular/epidemiología , Isquemia Encefálica/diagnóstico , Femenino , Florida/epidemiología , Humanos , Hemorragias Intracraneales/diagnóstico , Masculino , Estudios Retrospectivos , Accidente Cerebrovascular/diagnósticoRESUMEN
BACKGROUND: A non-anion gap acidosis can be induced by topiramate, causing symptomatic dyspnea and confusion. OBJECTIVES: Discuss the pathophysiology of the hyperchloremic metabolic acidosis caused by topiramate, the typical clinical presentation, and the recommended treatment. CASE REPORT: This case presents a young woman with a clinically significant non-anion gap metabolic acidosis believed to be caused by topiramate. She had been taking the medication for several months without prior adverse effects. Once she began having dyspnea as a respiratory response to the renal tubule acidosis, she had decreased oral intake of food and fluids, which induced a pre-renal acute renal failure that worsened her acidemia. In the Emergency Department, she received intravenous fluids and sodium bicarbonate, and later was intubated for mechanical ventilation due to respiratory fatigue. With the topiramate withdrawn, the patient had a full recovery of her renal function and metabolic acid-base status over the next 72 h. This case serves to increase awareness of this possible adverse effect and the recommended treatment as topiramate becomes more widely used. CONCLUSIONS: Topiramate can induce a renal tubule acidosis resulting in a hyperchloremic metabolic acidosis. Recognition of the underlying cause is crucial so that the drug can be withdrawn while supportive care is provided.
Asunto(s)
Acidosis/inducido químicamente , Fructosa/análogos & derivados , Fármacos Neuroprotectores/efectos adversos , Equilibrio Ácido-Base , Adulto , Femenino , Fructosa/efectos adversos , Humanos , TopiramatoRESUMEN
OBJECTIVES: This study aims to describe the population that averages one or more emergency department (ED) visits per month and compare them to the general ED population to determine if there are associated characteristics. METHODS: A retrospective cohort study conducted in a teaching hospital between January 1, 2001, and December 31, 2004, identified all patients with more than 35 visits. This hyper-user (HU) cohort (n = 49) was compared to a randomly selected group of non-HU patients (n = 50) on the following measures: age, sex, insurance coverage, primary medical doctor (PMD), dwelling location, chief complaint, comorbidities, and disposition. RESULTS: The HU group was significantly older (mean, 49.45 years) than the non-HU group (37.32 years) with a P < .0001. There was no difference between the groups in sex, insurance coverage, PMD, dwelling location, and disposition. A univariant logistical regression found that previous cardiovascular, genitourinary, or psychiatric disease were predictors of hyper-use. CONCLUSIONS: The HU group is older and more likely to have a history of cardiovascular, genitourinary, and psychiatric disease but is similar to the non-HU group in other measured parameters. The HU group appears to have equal access to a PMD and is not more likely to be admitted to the hospital than the non-HU group.