Prognosis of patients with extreme acidosis on admission to the emergency department: A retrospective cohort study.

AIM OF THE STUDY: The development of acidosis in critically ill patients is considered to be a negative prognostic factor, and when extreme, even incompatible with life. We aimed to test the prognosis of patients with a pH lower than 6.9 on emergency department admission. METHODS: A retrospective cohort study in adult patients admitted to two emergency departments with a pH < 6.9 during the first 12 h of admission. Primary outcome was mortality within 24 h from emergency department admission. We performed a regression analysis of clinical and laboratory data in order to identify factors associated with mortality in this population. RESULTS: We analyzed data of 206 admissions to the emergency departments between 2008 and 2018 with extreme acidosis. pH Values ranged from 6.898 to 6.35 (mean 6.8 and median 6.83). 60 (29%) of the patients survived the first 24 h. 35 patients (58%) of those also survived to hospital discharge, and of them 80% have returned to their previous functional status. Patient's age, type of acidosis, cardio-pulmonary resuscitation on arrival, and diagnosis on admission were correlated with survival. CONCLUSIONS: A small but significant portion of patients with extreme acidosis on emergency department admission survive at least to 24 h and until hospital discharge. The clinical decision making should be based on other prognostic factors rather than pH value by itself.

The role of single positron emission computed tomography imaging in the diagnosis of brain death whenever Trans-cranial Doppler fails to support it: A retrospective cohort study.

OBJECTIVE: Although there is widespread acceptance of the concept of brain death/death by neurologic criteria (BD/DNC), there is marked variability in the use of ancillary tests worldwide. Transcranial Doppler (TCD) is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. However, it is considered less sensitive than Single Photon Emission Computed Tomography (SPECT) Tc-HMPAO (99 m). This study aims to test the yield of brain perfusion SPECT testing after a TCD has demonstrated some level of intracranial blood flow among patients fulfilling clinical criteria for BD/DNC. METHODS: This was a single-center retrospective cohort study of all the patients fulfilling clinical criteria for BD/DNC who underwent brain perfusion SPECT after an intracerebral circulatory arrest was not confirmed by TCD between July 2016 and January 2022. RESULTS: TCD was an initial ancillary test performed in 252 patients (99.6%) fulfilling clinical criteria for BD/DNC. A complete circulatory arrest was demonstrated in 228 (90.5%) patients. Brain perfusion SPECT was performed in the remaining 24 patients. The absence of cerebral perfusion consistent with BD/DNC was found in 21 cases (87.5%). BD/DN could not be confirmed in three patients (12.5%). CONCLUSIONS: SPECT testing has a high diagnostic yield when TCD fails to confirm a suspected diagnosis of BD/DNC. Combining these two modalities may be an optimal strategy for BD/DNC diagnosis when this is required by local regulations or when confounding factors interfere with the performance of a complete clinical assessment.

Assessment of Alternative Personal Protective Equipment by Emergency Department Personnel During the SARS-CoV-2 Pandemic: A Simulation-Based Pilot Study.

STATEMENT: Shortage of personal protective equipment (PPE) for frontline healthcare workers managing the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a major, global challenge. In this pilot study, we describe a simulation-based method for evaluating the suitability and acceptability of an alternative biological isolation garment (BIG, a gown or a suit) for clinical use by emergency department (ED) personnel. Using a high-fidelity simulator, participants provided airway management according to the SARS-CoV-2 protocol. A nonvisible fluorescent marker was used as a surrogate marker of contamination. We assessed ultraviolet light visualization of the fluorescent marker after doffing and satisfaction with donning, use during simulation, and doffing. We found that after doffing, markers were not visualized on any of the participants and that the median satisfaction scores of the alternative and standard BIG (sBIG) were 4 [interquartile range (IQR) = 1-5] and 4 (IQR = 2-4), respectively. The results suggest the suitability and acceptability of the alternative BIG (aBIG) for use by ED personnel.

Diagnosis of ABCC8 Congenital Hyperinsulinism of Infancy in a 20-Year-Old Man Evaluated for Factitious Hypoglycemia.

CONTEXT: Hypoglycemia is a rare event in healthy adults, and the differential diagnosis includes many diseases, some of which are rare and easily missed. DESIGN, SETTING, DESCRIPTION: A 20-year-old male military paramedic was referred to our emergency department for investigation of recurrent hypoglycemia episodes during the previous months. Factitious hypoglycemia was excluded, and organic hyperinsulinemic hypoglycemia was diagnosed by the findings from a prolonged fast. The findings from endoscopic ultrasonography and triple-phase computed tomography were normal. Before additional diagnostic tests or exploratory surgery were performed, a deeper interrogation of the patient and his family revealed events compatible with episodes of hypoglycemia since childhood. Moreover, a single event of hypoglycemia during childhood was documented in 1 brother, suggesting the possibility of an inborn, inherited metabolic disease. Because the patient was Ashkenazi Jewish, we suspected the presence of 1 of 2 common founder mutations in the ABCC8 gene, which codes for 1 subunit of the ß-cell adenosine triphosphate-sensitive potassium channel, known to cause congenital hyperinsulinism of infancy. Direct sequencing revealed homozygosity for the ABCC8 gene mutation 3989-9 G>A. CONCLUSIONS: The differential diagnosis of hyperinsulinemic hypoglycemia in a young healthy adult should include genetic disorders of glucose homeostasis. In the Ashkenazi population, rapid and inexpensive screening for 2 founder mutations can confirm the diagnosis, avoiding expensive, invasive, and potentially dangerous diagnostic procedures.