[A Case of Methemoglobinemia Caused by Toluidine Revelation with Dyspnea and Cyanosis].

Toluidine is a known cause of bladder cancer, but it is less widely recognized as a cause of methemoglobinemia because methemoglobinemia is rare. We herein report a case of methemoglobinemia caused by toluidine in a 50-year-old man. A solution of toluidine overflowed from its container during transportation and adhered to the man's clothes, but he drove to his workplace 100 km away without changing his clothes or undergoing decontamination. Before arriving at his workplace, he developed dyspnea and called emergency services, and he was then transported to a local hospital. He had significant cyanosis upon arrival, and arterial blood gas analysis revealed a high methemoglobin level of 44%. He was diagnosed with toluidine-induced methemoglobinemia and was transported to our hospital, where he was admitted to the intensive care unit. Treatment for methemoglobinemia was started immediately after hospitalization, and the patient's symptoms and methemoglobin level improved. Methemoglobinemia should be considered in workers who handle toluidine and develop cyanosis and dyspnea.

Risk prediction of biomarkers for early multiple organ dysfunction in critically ill patients.

BACKGROUND: Shock and organ damage occur in critically ill patients in the emergency department because of biological responses to invasion, and cytokines play an important role in their development. It is important to predict early multiple organ dysfunction (MOD) because it is useful in predicting patient outcomes and selecting treatment strategies. This study examined the accuracy of biomarkers, including interleukin (IL)-6, in predicting early MOD in critically ill patients compared with that of quick sequential organ failure assessment (qSOFA). METHODS: This was a multicenter observational sub-study. Five universities from 2016 to 2018. Data of adult patients with systemic inflammatory response syndrome who presented to the emergency department or were admitted to the intensive care unit were prospectively evaluated. qSOFA score and each biomarker (IL-6, IL-8, IL-10, tumor necrosis factor-α, C-reactive protein, and procalcitonin [PCT]) level were assessed on Days 0, 1, and 2. The primary outcome was set as MOD on Day 2, and the area under the curve (AUC) was analyzed to evaluate qSOFA scores and biomarker levels. RESULTS: Of 199 patients, 38 were excluded and 161 were included. Patients with MOD on Day 2 had significantly higher qSOFA, SOFA, and Acute Physiology and Chronic Health Evaluation II scores and a trend toward worse prognosis, including mortality. The AUC for qSOFA score (Day 0) that predicted MOD (Day 2) was 0.728 (95% confidence interval [CI]: 0.651-0.794). IL-6 (Day 1) showed the highest AUC among all biomarkers (0.790 [95% CI: 0.711-852]). The combination of qSOFA (Day 0) and IL-6 (Day 1) showed improved prediction accuracy (0.842 [95% CI: 0.771-0.893]). The combination model using qSOFA (Day 1) and IL-6 (Day 1) also showed a higher AUC (0.868 [95% CI: 0.799-0.915]). The combination model of IL-8 and PCT also showed a significant improvement in AUC. CONCLUSIONS: The addition of IL-6, IL-8 and PCT to qSOFA scores improved the accuracy of early MOD prediction.

Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock Due to a Gastric Ulcer: A Case Report.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct procedure designed to sustain the circulation until definitive hemostasis is obtained. The device is indicated in trauma patients with abdominal trauma and/or pelvic fractures, but there is limited evidence for its use in gastrointestinal bleeding. A 76-year-old woman was admitted to the emergency department of our hospital because of shock, manifesting as hematemesis. We performed emergency endoscopy and detected active bleeding from a gastric ulcer. Achieving hemostasis was difficult, and she experienced shock again during the procedure, leading to cardiopulmonary arrest. REBOA was performed after the return of spontaneous circulation because she continued to be in a state of shock. Her blood pressure rose, and endoscopic hemostasis was continued with balloon inflation, but it didn't stop the bleeding completely, so we shifted to emergency laparotomy and performed suture hemostasis. The patient developed no postoperative complications and was transferred to another hospital. REBOA can be effective at improving the hemodynamic status in patients with uncontrollable gastrointestinal bleeding.

Early Enteral Nutrition is Related to Decreased In-hospital Mortality and Hospitalization in Patients with Acute Pancreatitis: Data from the Japanese Diagnosis Procedure Combination Database.

Management of early nutrition plays an important role in the treatment of acute pancreatitis patients, but the sample sizes of randomized control trials that have compared enteral and parental nutrition were small. From the data of Diagnostic Procedure Combination, we identified patients who had been diagnosed with acute pancreatitis and discharged from the hospital between 2014 and 2015. We compared the length of hospital stay and hospital mortality among patients with acute pancreatitis that was managed with and without enteral nutrition within 7 days from hospitalization. The results showed a significant decrease in the in-hospital mortality rate of 56% (odds ratio 0.444, 95% confidence interval [CI] 0.358 - 0.551, P < 0.001) and length of hospital stay by 8.6 days (95% CI -9.05 - -8.13, P < 0.001) when enteral nutrition was administered within 7 days. According to multivariate analysis, early enteral nutrition was independently associated with in-hospital mortality rate and length of hospitalization. Enteral nutrition is an important management method for the treatment of acute pancreatitis patients.

Respiratory Acidosis as a Diagnostic Clue in Symptomatic Epilepsy With Stroke Mimics: A Case Report.

Stroke mimics are difficult to differentiate from each other. Symptomatic epilepsy can also occur, but it is necessary to perform a magnetic resonance imaging (MRI) scan to distinguish it from a stroke. Although respiratory acidosis has been reported to occur with partial-onset seizures due to prolonged apnea, respiratory acidosis is rarely suspected to be a sign of epilepsy. We report a case in which respiratory acidosis helped to diagnose symptomatic epilepsy with stroke mimics. The patient was a 52-year-old female who was brought to the emergency room with the chief complaint of difficulty in talking. When she visited the hospital, sensory aphasia was observed, and a computed tomography (CT) scan was performed. She vomited after the CT scan, and an arterial blood gas analysis showed a pH of 7.26 with a PaCO2 level of 71 mmHg, indicating respiratory acidosis. After the administration of diazepam, the seizures abated and her sensory aphasia improved. Later, an investigation of the patient's history revealed symptomatic epilepsy and discontinuation of antiepileptic drugs. If unexplained respiratory acidosis is noted in a patient with stroke mimics, a further investigation of the patient's history and physical examination may help to diagnose symptomatic epilepsy.

Association of frailty on treatment outcomes among patients with suspected infection treated at emergency departments.

BACKGROUND: The clinical frailty scale (CFS) score has been validated as a predictor of adverse outcomes in community-dwelling older people. Older people are at a higher risk of sepsis and have a higher mortality rate. However, the association of frailty on outcomes in patients with sepsis has not been completely examined. OBJECTIVE: This study evaluated the association between CFS and outcomes in patients with sepsis. DESIGN: This was a multicenter prospective cohort substudy. SETTINGS AND PARTICIPANTS: The study included 37 emergency departments from across Japan. The patients (age ≥16 years) were included in this study if they had suspected infection at an emergency department during December 2017-February 2018. OUTCOME MEASURE AND ANALYSIS: The primary outcome was 28-day mortality, stratified by the CFS score categories. The secondary outcomes were the duration of hospital stay, number of ICU-free days (ICUFDs) and number of ventilator-free days (VFDs). MAIN RESULTS: A total of 917 patients were included. The median age was 79 years. The CFS score was associated with an increased risk of 28-day mortality and with a higher likelihood of long-term hospital stay and short-term VFDs and ICUFDs. Multivariate logistic regression analysis indicated that the CFS score was a predictor of 28-day mortality [odds ratio (OR), 1.26; 95% confidence interval (CI), 1.11-1.42]. CONCLUSIONS: This study reported that in patients with suspected sepsis in the emergency department, frailty may be associated with poor prognosis and length of hospital stay.